Inspection on 13/03/06 for Faithfull House

This inspection was carried out on 13th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Faithfull House 25/01/10

Faithfull House 29/01/07

Faithfull House 22/09/05

Faithfull House 03/03/05

Faithfull House 19/10/04

Faithfull House 17/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Faithfull House Suffolk Square Cheltenham Glos GL50 2DT Lead Inspector Malcolm Kippax Unannounced Inspection 13th March 2006 09:20 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 Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 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. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Faithfull House Address Suffolk Square Cheltenham Glos GL50 2DT 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) 01242 514319 01242 578392 Cheltenham Old People`s Housing Society Limited (The Lilian Faithfull Homes) Mrs Suzanne Dawn Booker Care Home 72 Category(ies) of Old age, not falling within any other category registration, with number (72) of places Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd September 2005 Brief Description of the Service: Faithfull House is a substantial attractive property, originally three Regency Houses, which have been converted to provide accommodation for 72 elderly service users who require personal care. The home is owned and managed by a charitable organisation and is one of the Lilian Faithfull Homes. It is situated in the Montpellier area of Cheltenham, within easy access of shops and local amenities. Accommodation is provided on 5 floors of the home; 4 of which are served by 2 shaft lifts. Currently, access to other areas is provided by a number of stair lifts. In addition, a variety of aids and adaptations have been provided throughout the property to assist the service users. The majority of bedrooms have been equipped with en-suite facilities and assisted baths and toilets have been installed throughout the home. The communal areas on the ground floor consist of several lounges, a dining room and a conservatory. There is also a library and Chapel located on the lower ground floor. The service users have the benefit of well-maintained gardens at the rear of the property. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place from 9.20 am - 4.45 pm and focussed on some key standards that were not covered at the previous inspection. The outcome for service users was looked at during meetings with five service users in their own rooms and through discussion with the registered manager and deputy manager, three staff members and a relative. Some records were also examined. Refurbishment was having some impact on the home at the time, although service users will benefit from improved facilities in the future. What the service does well: What has improved since the last inspection? What they could do better: The home has received a detailed report about how medication is managed. Progress has been made with matters arising from this, although further action is needed to ensure that good practice is maintained in all areas. The home recognises that the general appearance in many areas could be better. A list of works has been produced and completion of this will enhance the environment and further improve the facilities for service users. Quality assurance, through informal arrangements and the manager’s and staff members’ on-going contact with service users could be further developed. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 6 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. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 7 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 Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 8 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): These standards were not looked at on this occasion. EVIDENCE: Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 9 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): 9 Service users take responsibility for their medicines to varying degrees and benefit from the support that they receive with this. The procedures are being developed to ensure that good practice is maintained in all aspects of medication administration. EVIDENCE: A pharmacist inspector from the Commission has previously looked at the medication arrangements in the home. A detailed report with requirements and recommendations was produced. The home’s deputy manager reported on the action that has been taken in connection with the report. The requirements have been responded to and some changes have been made to the storage arrangements and safekeeping of medication. A medicine cupboard on one floor is no longer used and lockable cabinets have been installed in the service users’ rooms. These were seen when meeting with service users and some service users said that they manage their medication independently. The deputy manager confirmed that there are different arrangements in place for self-administration depending on the service users’ wishes and a risk assessment; some service users taking responsibility themselves and others choosing to receive support from staff, who administer the medication from the individual cabinets. There are office based storage facilities in use for certain Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 10 medicines and for items such as eye drops that are administered by staff and need to be kept refrigerated. The deputy manager had initialled a checklist showing that she had undertaken an audit of medication procedures each month. This was up to date. The September 2005 edition of the British National Formulary was available. The staff members met with said that only senior carers are involved in the administration of medication. Some matters raised in the pharmacist inspector’s report have not been put into practice. These include the ‘strong recommendation’ for handwritten entries on the MAR charts to be signed by the staff member making the entry and checked by a second person. It would be beneficial for the report to be further looked at to ensure that all the recommended action and advice given is put into practice. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 11 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 and 14 Service users maintain independent lifestyles and appreciate the choice that they can make in some important areas. EVIDENCE: Five service users were met with in their own rooms, which each had a homely and individual appearance. The service users had brought with them a range of possessions and items of furniture when moving into the home. Some rooms had been divided to create separate living and sleeping areas. Rooms at the back of the home overlook the garden and a service user said that they could look after their own patch if they wished to do this. Service users looked well settled and occupied in their rooms. They can choose whether to spend time by themselves or to take part in the in-house activities programme. Details of the day to day events were displayed in the home. The manager and staff members said that the variety and number of social activities has increased since the last inspection. This has resulted in a fuller programme of activities each month. The manager said that holidays had been arranged for later in the year and that the University of the Third Age now held a session in the home. Service users mentioned the card and board games that they enjoy in small groups. Another service user spoke about her enthusiasm for poetry reading and concerts. A service user commented that it would be helpful if service users were introduced to some other people in the Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 12 home who might have similar interests. This was later discussed with the manager, who said that she was mindful of this when looking at who might like to sit together at meal times. One of the service users met with later went out to a bridge club in the afternoon. A relative was helping with this trip, although group transport can be arranged for planned outings. There is a library and a chapel on the lower ground floor. A minister visits the home each week although the chapel was not being used. The manager said that it would not be difficult for this to be put back into use. A number of visitors came and went during the inspection. Rooms are available for use by the service users’ visitors who wish to stay overnight. A notice about local advocacy contacts was displayed in the front hall. The manager, Suzanne Booker said that advocacy services had not been needed by the current service users. The home has a Visitors Committee, whose members visit some service users on a regular basis. A list has been drawn up showing who has chosen to receive this service. The home’s policies and procedures file includes polices on advocacy, data protection, confidentiality and sexuality. The latter states that ‘residents should be free to develop and maintain intimate personal relationships with people of their own choice’. The manager said that the home had no involvement in managing the service users’ financial affairs and that the service users themselves deal with this with, often with the support of relatives. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 13 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 There are procedures in place which help to ensure that service user are protected. EVIDENCE: There is a policy and procedure for the Protection of Vulnerable Adults. This was dated 11 August 2004. No review date was seen; it is good practice to include one as a reminder to check from time to time that the contents continue to be relevant and up to date. The staff members met with said that they had seen the home’s guidance on P.O.V.A. and abuse. They also confirmed that they had received training through the organisation and seen a video on the subject. The manager confirmed that the training is given to all care and domestic staff. The manager said that no referrals had been made under the Protection of Vulnerable Adults procedure during the last year. The manager expressed confidence about what to do and confirmed who would be contacted if a referral was needed. The home has not needed to have contact with the local vulnerable adults unit. A police officer from the unit may be available to talk to staff about their work. This could be a useful addition to the training and guidance that the staff team already receive. The home’s policies and procedures file includes guidance for staff in a range of relevant areas, such as whistle blowing, restraint, and good practice concerning gratuities and gifts. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 14 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): 26 The accommodation is kept clean and tidy. Service users receive the support that they need with their own rooms. Service users will benefit from the completion of refurbishment and maintenance works that have been identified. This was having some impact on the home at the time of the inspection. EVIDENCE: A number of bedrooms and some bathroom and communal areas were seen. These areas looked clean and there were no unpleasant odours. Service users said that they are satisfied with the support they receive with their rooms. Laundry facilities are located on the lower ground floor and away from the food preparation areas. The washing machines have programmes that meet disinfection standards. There are also domestic type machines in other laundry rooms and one service user met with said she had used this facility. The manager said that the homes’ two sluices were functional but it was hoped to replace them with more modern facilities. Supplies of disposable gloves Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 15 were seen in some areas. The home has a policy on infection control, including M.R.S.A. Some of the bathroom and toilet areas have been refurbished since the last inspection. This programme of works had not been completed. One service user met with appreciated that the work would be an improvement but was concerned about the length of time it was taking, as she now had to make a longer walk to the bathroom. Standard 19 was not inspected on this occasion, other than to follow up a recommendation that the registered person provides an action plan with timescales detailing the continued upgrading and refurbishing of the home. The manager said that a plan with timescales had not been produced, although a list of works had been drawn up as part of a building survey report, dated February 2006. A copy of this was received during the inspection. The report is comprehensive and includes various works that will improve the environment. The report mentioned an ‘urgent requirement’ to check one of the staircases. This staircase was out of use at the time of the inspection. The manager has reported that a risk assessment has been undertaken and that service users have not been adversely affected. It was anticipated that the necessary work would be completed in 2 –3 week. One of the lifts was also out of use at the time of the inspection, which meant that some service users had a longer walk to their rooms from the other lift, which is new, or from another staircase. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 16 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): These standards were not looked at on this occasion. EVIDENCE: Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 17 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 and 35 Service users benefit from the registered manager’s experience and the approach that is taken to the running of the home. There are recognised systems in place for quality assurance within the organisation, although the more informal arrangements involving service users could be further developed. There are procedures in place that help to safeguard the service users’ interests. EVIDENCE: Standard 31 was exceeded when last inspected and there have been no changes affecting the management of the home since that time. Suzanne Booker has been the registered manager at Faithfull House for over five years and has also had experience of managing another home within the Lilian Faithfull group. Suzanne Booker has gained a nursing qualification and a certificate in management studies, and is an NVQ assessor. Suzanne Booker Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 18 said that she continued to participate in training events and had attended courses during the last year that included the subjects of bereavement, terminal care, drugs and diabetes. A deputy manager has specific responsibilities within the home, for example dealing with medication. There are senior carers who take the lead when working alongside care staff. A monthly meeting is held involving managers from the Lilian Faithfull homes. The staff members (two carers and a senior carer) said that they felt supported in their work. The comments from service users indicated their satisfaction with the running of the home, with the management described as being good, or very good. The manager was observed to be assisting service users in the dining area and spoke positively about her management role and how she kept in touch with all aspects of the home. Standard 33 was exceeded when last inspected. The manager said that the registered provider has received ‘Investors in People’ accreditation and continues to use the ISO 9001 quality assurance system, which involves a monthly internal audit and an annual external verification. The manager also described the means by which feedback has been obtained from service users. This has included the use of comment cards and questionnaires, although the latter are reported to have produced only a limited response. There are separate arrangements in place by which service users can comment on the meals, which are prepared by outside caterers. A residents committee meets every 3- 4 months and the minutes of the last meeting on 5 December 2005 were seen. Service users described some ways in which they can pass on their views, which mainly involved raising these with the manager or a staff member. The service users and the relative met with were open in their comments about the home. For example, one suggestion was made that if staff wore a type of badge, this would help service users get to know their names. It appears that service users can readily contribute their views and that there are various means by which they can do this. It would be worthwhile to develop these as part of a co-ordinated approach to quality assurance within the home. All service users entering the home are required to have powers of attorney in place. The manager said that the home was not looking after any cash on behalf of service users, although this service would be available if requested. Standard 38 was not inspected on this occasion, other than to follow up a requirement that was made at the last inspection. This concerned items of work that had been specified by the fire safety officer. The manager said that these had been implemented, other than for the completion of a cupboard that was being upgraded. This was expected to be completed within the next two weeks. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 19 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X X Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 23(4) Requirement All the requirements specified by the fire safety officer to be implemented. (This requirement has not been fully met by the timescale of 31/12/05 that was identified at the last inspection). Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP9 OP12 OP18 OP19 OP19 Good Practice Recommendations That the pharmacist inspector’s report is further looked at to ensure that all the recommended action and advice given is put into practice. That the chapel is available to be used when a minister visits the home. That the local vulnerable adults unit is contacted to see whether a police officer from the unit is available to talk to staff in the home. The registered person should provide an action plan with timescales detailing the continued upgrading and refurbishing of the home (not met at last inspection). That the Commission is informed of the progress being DS0000016436.V285721.R01.S.doc Version 5.1 Page 21 Faithfull House 6 OP33 made with refurbishment and maintenance work in the home (this could be done through the reports of visits that are made to the home under Regulation 26 of the Care Homes Regulations 2001). That the arrangements for obtaining feedback from service users are included within the home’s system for quality assurance. A plan or policy for quality assurance should show how the service users’ views are contributing to annual development and improvement in the home. Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Faithfull House DS0000016436.V285721.R01.S.doc Version 5.1 Page 23 - 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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