Inspection on 22/09/05 for Faithfull House

This inspection was carried out on 22nd September 2005.

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

Faithfull House 25/01/10

Faithfull House 29/01/07

Faithfull House 13/03/06

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 G Goldfinch Unannounced Inspection 17:30 22 September 2005 nd 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.V251592.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. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 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 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.V251592.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 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.V251592.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours from 5.30 – 9.30 pm. The inspection was carried out as part of the regular planned programme of inspections. A brief tour of the premises took place, and a selection of staff and care records were examined. Some health and safety documents were also seen. The registered manager, seven of the care staff on duty, and six residents were spoken to during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The fire safety officers’ requirements need to be acted upon. An action plan for the refurbishment and redecoration of the building needs too be in place to show that there is a continual planned upgrade. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 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.V251592.R01.S.doc Version 5.0 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.V251592.R01.S.doc Version 5.0 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): 3, 5 Residents’ needs were assessed and they were able to visit the home to help them make a choice about whether they wanted to move there. EVIDENCE: An assessment document was seen which covered all areas of residents’ needs. Two residents who had recently been admitted to the home confirmed that they had been visited and assessed by the home before moving in. Both residents were able to say that they had been able to visit the home and have a look around before admission. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 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): 7, 8, 10 Care planning systems in the home ensure that residents needs are understood and met. EVIDENCE: Documentation that was seen during the visit indicated that residents’ needs were known and understood by the care staff. Care staff who were spoken to confirmed that they had an input into the care plans and residents were confident that their needs were being met. One resident said “My needs are more than met”. Daily records showed that the primary health care team were consulted and called in as necessary and residents had access to chiropody, opticians and dental services. One resident said she had been able to keep her own G.P after she had moved into the home. Observations made during the inspection showed the staff were respectful and promoted residents dignity. Residents were able to confirm that staff respected their privacy and one resident said they did not feel compromised when receiving personal care. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 10 Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 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): 12,13,15 Activities provided in the home cater to individual needs of the residents providing them with meaningful ways of spending their time. EVIDENCE: There was an activities programme which indicated a wide variety of different activities for residents to choose from. Transport was provided and residents were actively encouraged and supported to continue with community-based pastimes. There was an activities organiser who spent time with residents getting to know their preferences. The home also has an extensive library and its own chapel. Visitors were welcomed into the home at any time and guest rooms were available for those wanting to stay. Residents who were spoken to gave differing opinions about the choice of food in the home. The menus indicated that there was a variety of food each day and minutes from the recent residents meeting showed that the issue of choice was being managed. One resident said “the food is excellent” and another said “the choice of food was limited”. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 12 Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 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): 16 The complaints process in the home is good. Residents feel that staff are approachable and are confident to discuss any concerns, knowing that they will be taken seriously. EVIDENCE: A complaints procedure was available in the home and the residents’ who were spoken to felt confident that they would be listened to by the registered manager. A copy of the complaints procedure is provided to each resident and their representatives at the time of admission. The procedure was also seen to be attached to each of the notice boards in the home. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 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): 19 The home provides a homely environment for the residents to live in. EVIDENCE: Externally the home is well maintained and is an attractive building. However, some areas in the home were seen to be in need of redecoration and or refurbishment. Whilst a maintenance programme was not seen there was evidence that the home was being upgraded. This included a new lift being fitted, Trenchard room being redecorated and new chairs being provided. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 29 30 Arrangements for the induction of staff are good and staff receive appropriate training in order to ensure they have the necessary skills and knowledge to care for residents and to ensure their ongoing safety. EVIDENCE: The rota’s showed that there was a minimum of six staff on duty although the mornings were generally covered by eight members of staff. Care staff were supported by cooks, domestic staff and kitchen assistants. There were five members of staff on duty during the night. The home is committed to NVQ training and the majority of staff held the qualification. Staff recruitment files were examined and all the required information and checks were in place. Induction training for new members of staff was in place and specialist training was provided this included dementia training and bereavement counselling. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 16 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): 32,37,38 The health and safety aspects of the home were managed well ensuring that residents were not placed at risk in the environment. EVIDENCE: The registered manager communicates a clear sense of direction and leadership to which staff and residents were able to relate. Fire safety documentation was seen. The fire safety officer inspected the home in August 2005, and highlighted several issues for action. Discussions have since taken place and the home is working with the fire officer to address the issues. There were systems in place for risk assessments to ensure the safety of residents and staff at all times. Staff were aware of health and safety issues in the home and the purpose of risk assessments. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 17 All records examined were appropriately maintained. It is recommended that the handover record is signed by the staff member completing the document. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 18 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 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x x x 3 2 Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 19 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 OP38 Regulation 23(4) Requirement All the requirements specified by the fire safety officer to be implemented Timescale for action 31/12/05 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 OP19 Good Practice Recommendations The registered person should provide an action plan with timescales detailing the continued upgrading and refurbishing of the home. Faithfull House DS0000016436.V251592.R01.S.doc Version 5.0 Page 20 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. 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