Inspection on 16/11/05 for Fallowfield

This inspection was carried out on 16th November 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

Fallowfield 12/08/08

Fallowfield 20/09/06

Fallowfield 22/04/05

Fallowfield 26/01/05

Fallowfield 20/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Fallowfields 14 Great Preston Road Ryde Isle Of Wight PO33 1DR Lead Inspector Annie Kentfield Unannounced Inspection 16th November 2005 11.20 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 Fallowfields DS0000012490.V250822.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. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fallowfields Address 14 Great Preston Road Ryde Isle Of Wight PO33 1DR 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) 01983 611531 01983 868446 Mr Keith John Betteley Mrs Jennifer Ann Betteley Carol Ann Montague Care Home 21 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (9) Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd April 2005 Brief Description of the Service: Fallowfields is registered to provide residential care to twenty-one older people, including eight people with dementia. The home was formerly a Victorian residence, converted to provide accommodation on the ground and first floors with access to the upper floor via a passenger lift or stair lift. Set in a pleasant residential area of Ryde there is a garden and seating area for the residents at the front and to the rear of the building. The current owners took over the home four years ago and have made many improvements to the homes environment. The home also provides respite day care and respite residential care when there is a room available. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of Fallowfields and took place between 11.30 am and 4.30 pm on a Wednesday. The inspection included a tour of the premises, inspection of some of the home’s records and discussion with some of the residents and the manager. At the time of the inspection there were 20 residents with the manager and 3 care staff on duty. In addition, the home employs a cook, cleaner and maintenance person. The home was clean and tidy and warmly heated at the time of the inspection. An additional inspection visit was made on 30th November and the registered manager confirmed that all of the requirements and recommendations made at the inspection had been addressed immediately. What the service does well: What has improved since the last inspection? Since the last inspection some of the bedrooms that were being re-decorated are finished and residents have moved into these rooms. A separate sitting room is available for residents who smoke. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 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. Fallowfields DS0000012490.V250822.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 Fallowfields DS0000012490.V250822.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 All prospective residents have an assessment of their care needs before being offered a room in the home. The home does not offer intermediate care. EVIDENCE: Records show that the home uses a number of assessment tools to assess the care needs of prospective residents. Further assessment of care needs continues after a resident moves into the home and an individual care plan is drawn up. The manager is very aware of the home’s conditions of registration and the level of care that the home can provide. The manager does initial care assessments or one of the two deputy managers and additional information is requested from the family or other representative or the Local Authority care manager if appropriate. Wherever possible residents are encouraged to visit the home before moving in. The manager will also sometimes assess Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 9 prospective new residents in hospital if they are awaiting discharge from hospital. In discussion the manager explained that the assessment tools currently being used are sufficient for the initial care assessment but that assessment procedures are always being reviewed and improved. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 10 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): 8, 9 and 10 All residents have an individual plan of care and care staff meets the health care needs of the residents. EVIDENCE: Records show that the health care needs of the residents are monitored daily by the care staff and a daily record of care is kept for each resident. At each shift change, important information for staff is written in the daily communication book for all staff to read. The manager and deputy managers demonstrate a good knowledge and awareness of the individual health care needs of all the residents and act promptly if a resident is unwell. The manager and the deputy managers have a good working relationship with the local GP surgeries that residents are registered with and any concerns about individual residents are referred to their GP. The District Nurse or continence advisor sees those residents who need monitoring for pressure sores or continence care. The chiropodist and physiotherapist can see residents in the home and the local clinic provides a dental service. Optician appointments can be arranged in the home or an appointment made for a clinic visit. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 11 Care staff have done training in oral health care and recently dementia awareness. The medication is kept in a locked cupboard in the sitting room and one of the deputy managers is responsible for ordering and checking medication and training new staff in dispensing and administration. There are no residents who self-medicate. Although there were no particular problems identified with the home’s medication procedures the manager did suggest that a medication review would be welcome as procedures in the home have not been specifically reviewed for a number of years and records of staff meetings did record that there have been a couple of incidents where staff forgot to record dispensed medication. It was agreed that the medication review pharmacist be asked to look at the home’s medication policies, procedures and staff training as good practice. In discussion with some of the residents they confirmed that staff listen and take note of residents’ wishes and that staff always come to help when the alarm call is used. Residents said that staff respect privacy and they can have a lock on their bedroom door if they want to. There is a telephone that can be used by residents although this is in the entrance hall. Some of the residents have had their own telephone installed in their room. Fallowfields DS0000012490.V250822.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 - 15 There are organised social activities for residents although the inspection recommends that a more organised approach to activities could be made that takes into account the different abilities of the residents in the home. Residents spoken to said they were happy with the food and meals provided. EVIDENCE: A number of social activities are available for residents: a monthly slide show, music sessions, (usually weekly), and occasionally there is a religious service arranged by a local clergyman. Staff do bingo sessions and occasionally one of the staff will offer manicure treatments. There is also a hairdresser who visits the home weekly. The home does have a ‘mobility’ vehicle that can be used to take small groups of residents out and cars are also used. Some of the residents said they particularly enjoy the trips out and would welcome more opportunities for trips and outings. An outing is planned in December to visit a local Garden Centre and Christmas Shop. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 13 In discussion it was recommended that a programme of activities could be offered so that residents know in advance what activity is on offer. The needs and abilities of the residents vary greatly and the activities need to be able to offer something that meets all individual needs and preferences. Residents are welcome to have visitors at any reasonable time. The home has a very pleasant separate dining room although many of the residents choose to take their meals in their room or in the sitting room. The menus offer a varied and balanced diet and residents’ particular dietary needs are catered for. It was recommended that where meals are taken to residents’ rooms, these could be carried on a tray and plates preferably covered. The inspection noted that not all bedrooms had a table for eating at but the manager explained that residents are offered a table and this would be provided if residents choose. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 14 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 - 18 The home has a complaints procedure but the complaints file was being updated and will be looked at the next inspection. There are policies and procedures in place to protect residents, however, the recruitment procedures must be reviewed to meet the requirements of the current regulations in order to ensure that residents are protected at all times. EVIDENCE: The complaints file was being updated and was not available for inspection. This will be looked at the next inspection. The manager explained that recently some residents had asked if staff could open their mail for them and the manager has produced a disclaimer form that records residents’ consent to this. The manager has recently done some training in adult protection procedures ‘training for the trainers’ and there are plans to feed this back to all of the staff. Employment procedures are discussed under Standard 29. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 15 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 - 26 On the whole, the building is well maintained and in good order. A maintenance person is employed on a full-time basis and the work to maintain the building in good repair both externally and internally is ongoing. Where problems were noted during the inspection, these were discussed with the manager and either a recommendation or requirement made. Residents spoken to said that they were happy with their own room and had everything they wanted. EVIDENCE: All of the bedrooms are single occupancy and residents’ rooms are individually furnished and decorated and personalised with their own possessions. The home has a dining room, sitting room, and an additional small room on the ground floor that is used by residents who smoke; this room is about to be decorated. The bedrooms vary in size but all are of sufficient size for residents to have an armchair and television if they want to and some of the rooms are large enough to offer a ‘bed-sitting’ room. The carpet in one bedroom needs Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 16 to be replaced and this was discussed with the manager who explained that they were aware of this and a new carpet had been ordered. The inspector spoke to the cleaner who has worked in the home for some time and there is a regular routine for the cleaning of residents’ rooms and the other areas of the home. All parts of the home except one were free from unpleasant odour and the manager confirmed that this was being addressed. Unfortunately the sitting room carpet has suffered some damage with iron scorch marks but as the home was planning to add a conservatory to the sitting room, previous inspections said that the carpet could be replaced when this work was done. A specific period of time has now been allowed for the conservatory plans to be developed and a requirement made that the sitting room carpet must be replaced if the conservatory does not go ahead. The home’s decoration and furnishing is ‘homely’ and comfortable and appears to meet the needs of the residents in the home. Some of the bedrooms are more suitable for those residents who use a wheelchair or other mobility aids and there is a toilet on the ground floor close to the sitting room. The kitchen and laundry are in the basement and this area is not accessible for residents. There is a passenger lift, and a stair lift has been installed in case of lift failure at any time. Residents do not use one of the first floor bathrooms. The manager explained that it is now used by staff for cleaning and sluicing. This room must be kept locked, or if left open, cleaning materials must be stored in a locked cupboard. Residents use the other two bathrooms that have assisted bathing facilities. Two bedroom doors were being wedged open and the manager is aware that this is a risk to fire safety in the home. Action is being taken to fit self-closing mechanisms that are approved by the Fire Safety Officer. The baths are fitted with pre-set valves and all baths are checked with a thermometer before use. A check must be made of the temperature of water in wash-hand basins, some of them were very hot, and a risk assessment undertaken where appropriate and thermostatic valves fitted where appropriate. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 17 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 There are sufficient numbers of staff to meet the care needs of the residents and there is an ongoing staff-training programme. EVIDENCE: The staffing rota shows that there are 3 care staff and the manager on duty between 7.30 am and 5.00 pm with 2 care staff between 5.00 pm and 7.30 am with another person available to be called when needed. The home also employs 2 cleaners, a cook, and a maintenance person. There is a care staff team of 12 people and 9 of the team have already achieved NVQ level 2 in care and 2 others are currently enrolled to achieve this qualification. The home has recently introduced a key worker system. The manager confirmed that new staff follow a structured induction programme, however, these records were not available in the home, as required by regulation, and will be looked at during the next inspection. The manager confirmed that all staff have received training in the compulsory areas of health and safety and safe working practice, some of the staff are waiting to do first aid training and one person is waiting to do medication training. In discussion with the manager, it was recommended that a stafftraining matrix would make the record of staff training easier to manage and the manager could check at a glance when training needs to be updated. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 18 Three employment files were inspected and it was noted that there are some gaps in the information gathered. The Amended Care Homes Regulations require homes to make a number of checks on new care staff in order to protect vulnerable residents and the home’s recruitment procedures must be revised to meet the regulations. The requirements were discussed in detail during the inspection and confirmed in a separate letter to the registered manager with a copy of the most recent guidance on Criminal Record Bureau and other checks. Fallowfields DS0000012490.V250822.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, 36, 37 & 38 The home is well run with experienced and qualified manager and staff and in the best interests of the residents. EVIDENCE: The manager has achieved NVQ level 3 and 4 in care and has recently completed the NVQ level 4 in management and explained that she is awaiting verification of this award. The manager is also an accredited NVQ assessor. The manager has a positive and energetic approach to managing the home and works closely with the two owners who are in the home on a regular basis. The manager and deputy managers are clear that the needs of the residents come first and set high standards for the way that the home is run. It was evident from observation and comments during the inspection, that residents and staff enjoy the relaxed and friendly atmosphere in the home. Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 20 Residents are encouraged to manage their own affairs or with help from family or legal representatives. The home has a policy that neither the manager nor staff can be directly involved in residents’ financial affairs. Where a resident lacks capacity and has no other person to help them, the manager provides information on how residents can access independent help or will make a referral to the Local Authority Social Services. The manager looks after small amounts of residents’ personal allowances and assists one or two residents to access their bank accounts. The systems and records in place for this are quite complicated but the manager explained that she wants to make sure that residents get the help in the way that they prefer and is happy to run various systems of looking after residents’ monies. Safeguards on all procedures are maintained and all transactions for residents are receipted and signed in a record book and double-checked by the manager or one of the deputy managers. All monies are kept locked in the safe that can only be accessed by 3 people. Residents can make a weekly shopping request and the individual amounts invoiced to the residents. The manager is still developing the home’s quality assurance system: questionnaires have been developed to gain some feedback from residents on their satisfaction with the home. This has produced some comments about menus and food that the manager is addressing. In discussion, it was recommended that the ‘customer satisfaction’ questionnaire could be developed to include relatives and professional visitors. More ways could be considered of getting feedback from residents such as resident meetings. It was also suggested that the ‘Thank You’ letters and cards that come from residents, relatives, friends and others, could be displayed, as these demonstrate that staff in the home are appreciated and highly thought of. The manager is in the process of updating the Fire Safety Risk Assessment and it is hoped that a fire safety training evening will be organised in the near future. The logbook for recording checks on the fire alarm and emergency lighting was up to date. The manager explained that surprise fire drills are occasionally held and it is recommended that a written record is kept of dates and a list of staff and/or residents who took part so that the manager can make sure that all staff take part in a fire safety practice at some point in the year. Fallowfields DS0000012490.V250822.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 N/A 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 2 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 N/A 3 3 2 2 Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 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 Standard OP29OP18 Regulation 19 & Amend Reg 2004 Requirement Residents must be protected by the home’s recruitment and employment procedures. These must include all the checks required by regulation, before new staff begin work in the home. The supply of water to washhand basins must meet the relevant environmental health and safety requirements and the needs of the individual residents. Carpet must be replaced in one of the bedrooms in the home (as identified during the inspection). The sitting room carpet must be replaced. If the conservatory is to be built within the next 6 months, the carpet can be replaced when this is completed. Records required by regulation must be available in the home for inspection. Doors in the home must not be wedged open. The registered manager must consult with the local Fire Safety Officer about all fire safety measures in the home. DS0000012490.V250822.R01.S.doc Timescale for action 16/11/05 2 OP25 13(4) 16/11/05 3 4 OP26 OP19 16(j)(k) 16(c) 30/12/05 30/06/06 5 6 OP37 OP38 17 23(4) 16/11/05 16/11/05 Fallowfields Version 5.0 Page 23 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 It is recommended that the social activities programme is developed so that residents know in advance what is available and is varied enough to meet all abilities and preferences. It is recommended that meals be delivered to residents’ rooms, if they choose, on trays or covered plates. Residents should have a suitable table in their rooms for eating meals. The home’s Quality Assurance system could be developed to provide a continuous and effective system for getting the views of residents and their relatives of the service the home provides. It is recommended that a record be kept of any fire drill/practice with the names of those staff and residents who took part. 2 OP15 3 OP33 4 OP38 Fallowfields DS0000012490.V250822.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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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