Inspection on 10/05/07 for Fairwinds

This inspection was carried out on 10th May 2007.

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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairwinds 11/11/08

Fairwinds 07/05/08

Fairwinds 12/12/05

Fairwinds 16/06/05

Fairwinds 03/03/05

Fairwinds 19/10/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Fairwinds Ferham House Kimberworth Road Masbrough Rotherham South Yorkshire S61 1AJ Lead Inspector Sarah Powell Unannounced Inspection 10 and 15th May 2007 09:45 th Fairwinds DS0000059236.V304540.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 Fairwinds DS0000059236.V304540.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. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairwinds Address 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) Ferham House Kimberworth Road Masbrough Rotherham South Yorkshire S61 1AJ 01709 565800 01709 565829 fairwinds@exemplarhc.com Ferham Healthcare Ltd Nazimuddin Abdool-Raheem Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: Fairwinds is a registered home for 20 people with a mental health diagnosis. The accommodation is on two floors with lift access. Bedrooms and communal rooms are situated on both levels and there are designated smoking areas. All the bedrooms are single occupancy there are ample bathing and toileting facilities for the people living at the home. The home is attached to the main offices of the company and is within walking distance of Rotherham town centre and on a bus route. The fees at Fairwinds Care Home at the time of the inspection ranged from £1167 to £3995 per week, however this is different for each person at the home as it is calculated by the number of care hours required for each person. It is therefore necessary to contact the home for further information. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and took place over two days. The inspection began on 10th May 2007 at 9:45am and finished at 17:00 the second day was on 15th May at 9:00 and finished at 16:45. As part of the inspection process the inspector spoke to 5 residents, 19 staff 5 visiting professionals, 3 visitors and the manager. During the inspection a tour of the building took place, observing the environment, staff and care practices. A number of records were examined these included medication, care plans, menus, staff rotas, recruitment and maintenance records also quality assurance systems. Feedback was given to the manager and responsible individual at the end of the second day. What the service does well: What has improved since the last inspection? Due to the recent difficulties identified between the staff groups, lack of supervision and poor communication there did not appear to be any improvements since the last inspection. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Full assessments were undertaken for prospective people who wished to live at the home. EVIDENCE: Assessments were seen in the care plans looked at these were very detailed and comprehensive and it was easy to determine if the needs of the person could be met by the home. Social services assessments were also seen in the care plans and the specific assessments for people with mental health problems were in the plans of care. This ensures the needs of people moving into the home can be met. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Changing health care needs were not clearly documented and people were not always supported to take risks as part of an independent lifestyle. EVIDENCE: The manager had developed a new care plan approach for the mental health needs of the people who live in the home and this was the care pathway. They were very detailed and comprehensive clearly identifying the mental health needs of each person. One person had lived at the home for over three months but did not have a plan of care, the record sheets were in the file but had not been completed. This had put them at potential risk, staff were not aware of their needs and how to manage them appropriately and safely. General health care needs were not clearly identified and documentation was insufficient. The people case tracked should have been seen by a chiropodist Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 10 and dietician yet this was not evident from the plan of care if it had been carried out. There was no evidence in the plans to determine if physiotherapist or occupation therapist advice had been obtained, yet a number of people required this service due to their changing needs. It was difficult to determine if the home was able to meet the peoples’ current needs, as the records were inadequate. This places people living at the home at a potential risk, which is avoidable. People who live in the home told the inspector they were able to make decisions about their lives and relatives also said the people in the home were given assistance to allow this. Yet evidence was not seen in some of the plans of care that this happened. Risk assessments were seen in the plans of care and were very good, risks had been identified and measures put in place to manage the potential risk to allow the people to have an independent lifestyle yet they were not always supported by staff to be able to do this. Some people told the inspector we are not always able to go out to the shop or park because the staff are not able to take us. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16 & 17. People who use the service experience adequate quality outcomes in this area (although the outcome for standard 17 meals was excellent). This judgement has been made using available evidence including a visit to this service. People in the home take part in appropriate activities but not always as often as they wished, access to the community is limited. Choice and quality of the meals was very good. EVIDENCE: The home employed two activity co-ordinators however one was due to go on maternity leave and no replacement had been allocated so the hours will decrease considerably and peoples recreational and leisure needs will not all be met. The activities provided in the home were excellent there was a designated craft room where the people in the home could participate in a number of craft activities, which many told the inspector they really enjoyed. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 12 Staff spoken to told the inspector the people in the home really enjoyed going out into the community to the local shops, park and pubs, however this has not been allowed to happen in the previous few months. This was due to lack of management direction and leadership but that a detrimental effect on the people living in the home. Staff also told the inspector that although there was a vehicle at the home for the people to use it was not always available as other homes also used it, therefore the routines in the home regarding leisure did not promote independence, individual movement and freedom of choice for the people who live there. Some people in the home had holidays booked but not all the people had been offered the opportunity to go on holiday and yet all of the people spoken to all would have liked to have been offered the chance of a holiday. It was also not clear if qualified nursing staff were going on the holiday, however the manager confirmed that qualified staff always accompanied the people who live in the home on holidays. Family links were well maintained, people and visitors all told the inspector that visitors are welcomed at any time. Private areas are available in the home as well as communal areas, people are free to chose which area they use. The home provided good quality food that was nutritious, varied and balanced. Numerous choices were available each day and meal times were very flexible. The cook regularly consulted with the people who lived at the home to determine their likes and dislikes and any special dietary requirement, this was documented and kept in the kitchen. The people at the home told the inspector that the food was very good and could eat when they wanted. People also told the inspector that a good choice of food was always offered. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 13 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 & 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal support is sensitive and flexible but not all health care needs are identified and met. Medication policies and procedures were good. EVIDENCE: Personal support is provided in a way the people who live at the home prefer and many people told the inspector that the staff are very good and help them when it was needed. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 14 Health care needs of the people are assessed and procedures in place to address them this was seen in the plans of care however not all health care needs were identified. It was not clear in the plans if chiropody or dietician involvement was obtained. It was also not evident if physiotherapist or occupational therapists were contacted for advice when required. Many of the people at the home required these services in order that their needs could be met. Staff told the inspector that when a person at the home required to use a hoist a occupational therapist was not contacted for advice and this should have been obtained. Relatives spoken to raised issues regarding the lack of chiropody and dietician input for their relatives in the home. They also said there was lack of communication regarding health care and what their relative required and received. The health care needs that had been identified in the plans of care were monitored and reviewed regularly this was evident in the plans. Medication procedures in the home were very good safeguarding the people in the home. One nurse was responsible for overseeing the medication orders and these were checked, signed for on receipt, administration and disposal. The lunchtime medication administration was observed by the inspector, the trolley and cupboard where it was kept was locked following each administration. The nurse gave medication to the person and it was then signed for once the person had taken the medication. This maintained accurate records to safeguard the people living in the home. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 15 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 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a good complaints procedure and a robust adult protection policy. EVIDENCE: The home has a comprehensive complaints procedure and details are in the service users guide and it is displayed in the entrance hall. The relatives spoken to were aware of how to raise a concern or complaint if the need arose and felt confident approaching staff and the manager with the concerns. The home also had a robust adult protection policy, two issues had been recently raised by the manager they were reported immediately and correct procedure was followed, to safeguard people in the home. One other referral was to Rotherham social Services, an investigating officer had been appointed to ensure the issue was resolved. Visiting professionals were in the home on the day of the inspection to investigate the referral and they told the inspector they had some concerns regarding the care provided for some people who live in the home this was following concerns raised by a relative of a person living in the home. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 16 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 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment was suitable for its stated purpose and the standard of cleanliness was good. EVIDENCE: The environment was homely, comfortable and safe. The home employed maintenance personnel and maintenance was carried out daily. Rooms were redecorated as required and furniture repaired or replaced when required. Many rooms were due redecoration, this had been identified by the manager and was being addressed to ensure the environment was well maintained for the people who live there The standard of cleanliness observed through out the home was good. Laundry facilities were provided and policies and procedures were in place for control of infection providing a clean hygienic home. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 17 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): 31, 32, 34, 35 & 36. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all staff were competent to carry out their roles, sufficient staff were on duty to meet peoples needs. Staff supervision was not being carried out. Recruitment procedures protect the people in the home. EVIDENCE: The staffing numbers on duty could meet the basic needs of the people in the home. However the recreational and leisure needs were not being met, as the staff were not always able to take the people out to the shops, park or pub as they requested. Staff told the inspector that they worked with five staff on nights and could do with six. Looking at the needs of people in the home and the layout of the building it would improve the care if six carers were on duty. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 18 There was a divide between care staff, qualified staff and management. There was no team working, which led to a negative impact on all people and staff in the home. All staff spoken to said there was lack of communication and supervision and management was not getting on top of the problems and they were getting worse. The staff team on days had sufficient number to meet needs of the people in the home yet was not effective as the team did not work together and therefore people’s needs were not being met. Supervision of staff was not being carried out so staff did not feel they had an opportunity to discuss any issues and problems they may have had. Therefore these were not resolved. Staff told the inspector they felt they were treated differently by management, depending on whether they were a carer or a nurse. Staff training was regularly updated and all staff had attended the mandatory training, although the last moving and handling training did not include use of the hoist. Many staff told the inspector they were not trained in use of the hoist and had to ask each other, as they needed to use a hoist on a person in the home. Evidence of training was seen in the staff files. Staff told the inspector they would like more specific training on mental health issues so they would be better equipped to deal with the people in the home and meet their needs. On occasions staff had to use restraint on people in the home, they did not feel they had enough training in this to deal with it safely. Recruitment procedures were robust and protected the people who live in the home. Two staff files were seen and they contained the required information and this was obtained prior to offer of employment. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 19 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, 38, 39 & 42. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is qualified and experienced, quality assurance systems are good and health and safety is maintained. However poor management of staff has caused a divide between staff and lack of teamwork, which had a negative impact on people living in the home. EVIDENCE: The manager is qualified and experienced to run the home and visitors commented he was approachable and listened. However staff did not feel he was resolving the issues with the staff team. There was not a clear sense of direction or leadership therefore have a detrimental impact on the people who live in the home. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 20 Quality assurance and quality monitoring systems were in place for the people who lived at the home, questionnaires were used to seek information and meetings with relatives and people in the home were held this was to seek their views to run the home in their interests. However it was not clear how effective this was as the staffing difficulties were having an impact on the quality of the lives of the people living in the home. The health and safety procedures in the home protected the people who live there. All safety checks were carried out and all certificates for gas, electrics, water, hoists and lift were seen and up to date. The maintenance personnel employed by the home ensure the fire alarms are checked and maintained and carry out environmental checks daily to ensure the safety of the environment for the people who live there. Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 21 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 3 3 X 4 X 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 1 32 1 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 1 14 2 15 3 16 2 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 2 2 X X 3 X Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 22 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. YA6 2. YA7 15 Standard Regulation 15 Requirement All people in the home must have a plan of care to ensure their needs are met. All people who live in the home must be supported to make decisions about their lives and this must be clearly identified in the plans of care. People who live at the home must be supported to participate and be part of the local community, by staff taking them on trips outside the home when they are requested. People who live at the home must have access to appropriate leisure activities outside the home. The routines in the home must promote individual choice and freedom of movement for the people who live there. All people who live at the home must be referred when necessary to all health care professionals and records maintained in plans of care. Health care needs must be identified and procedures in place to address them. DS0000059236.V304540.R01.S.doc Timescale for action 01/08/07 01/08/07 3. YA13 16 01/08/07 4. YA14 5. YA16 16 01/08/07 16 01/08/07 6. YA18 12 01/08/07 7. YA19 15 01/08/07 Fairwinds Version 5.2 Page 23 8. YA31 18 9. 10. 11. YA32 YA35 YA36 18 18 18 12. YA38 10 13. YA39 12 All staff must understand their roles and responsibilities to ensure they work as a team to benefit the people in the home. People in the home must be supported by competent staff to ensure their safety. All staff must be appropriately trained to meet people’s needs. All staff must be supervised at least six times a year to ensure they are able to carry out their jobs. The manager must give clear direction and leadership to ensure staff work as a team to benefit the people living at the home. The quality monitoring systems must be effective to ensure peoples’ views are listened to and it is run in their best interests 01/08/07 01/08/07 01/08/07 01/08/07 01/08/07 01/08/07 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 Fairwinds DS0000059236.V304540.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Fairwinds DS0000059236.V304540.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!