Inspection on 20/09/06 for Fallowfield

This inspection was carried out on 20th September 2006.

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

Other inspections for this house

Fallowfield 12/08/08

Fallowfield 16/11/05

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 Fallowfield 14 Great Preston Road Ryde Isle Of Wight PO33 1DR Lead Inspector Mark Sims Unannounced Inspection 20th September 2006 09:30 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 Fallowfield DS0000012490.V303880.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 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. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fallowfield 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 611531 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) Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Fallowfield 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 five 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. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first ‘Key Inspection’ for Fallowfield Residential Home, a ‘Key Inspection’ being part of the new inspection programme, which measures the service against the core and/or key National Minimum Standards. The fieldwork visit, the actual visit to the site of the home, was conducted over one day, where in addition to any paperwork that required reviewing the inspector met with service users, relatives and staff and undertook a tour of the premises to gauge its fitness for purpose. The inspection process also involved far more pre fieldwork visit activity, with the inspector gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service and linking with previous inspectors who have visited the home. The new process is intended to reflect the service delivered at Fallowfield over a period of time as opposed to a snapshot in time. What the service does well: What has improved since the last inspection? The following is an indication of the areas where the service has improved its performance: • • • • • Introduction of new recruitment and selection checklist New Common Induction Standards introduced. Thermostatic valves now installed on all sinks and baths Records required by the Commission to be retained on site are now available. The manager has completed an assessment of the home in accordance with the new fire regulations. DS0000012490.V303880.R01.S.doc Version 5.2 Page 6 Fallowfield 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. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 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 Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 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): St 3 & 6. Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. All service users are assessed prior to admission and provided with information relating to the service they can expect to receive whilst resident at Fallowfield. The home does not provide an intermediate care service. EVIDENCE: The evidence indicates that either the manager or her deputy assess service users prior to their admission. The evidence also suggests that all service users are aware of the services and facilities available at the home and that their health and social care needs are agreed prior to admission. Information gathered during the inspection process, which substantiates these judgements and findings includes: Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 9 • Pre-admission assessments: A number of completed pre-admission assessments were seen during the case-tracking process (a review methodology used by the Commission’s inspectors during visits), when five care plans were scrutinised. The care plans of three of the five service users found to contain an assessment tool, which appeared to address the principles set out in Standard 3 of the National Minimum Standards for Older People, a further plan noted to have a placement summary from a local authority care manager describing the person’ needs and reasons for admission. • In conversation with service users it was established that people recalled being visited either at home or in hospital and that generally the manager undertook these visits. A statement, supported by a comment in one of the seven professional comment cards returned, when it was remarked: ‘The home are helpful in assessing, promptly, for emergency admissions or discharges from hospital’. • Discussions with relatives established that it was a common occurrence for them to have visited the home on behalf of the next of kin, establishing the suitability of the environment and collecting information leaflets, etc, whilst at the home. The previous inspector also comments within her report that: ‘Records show that the home uses a number of assessment tools to assess the care needs of prospective residents’. The dataset also confirms that the home has a policy on the specific area of ‘Emergency Admission’ and that this policy was last reviewed and updated in December 2005. • • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 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): St 7, 8, 9 & 10 Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. The home’s care planning process provides sufficient guidance to staff around the service users’ care needs and how these are to be met. The health and social care support needs of the clients are well managed internally and are clearly meeting people’s needs. The home’s medication system is not being appropriately managed as records are being poorly maintained. The rights of the service users to be treated with respect and dignity are not being appropriately promoted by the practices of the staff/home. EVIDENCE: The evidence indicates that all clients or patients are provided with an individualised care plan, although the system is new and should be consistently and regularly monitored whilst the staff adjust to the changing format. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 11 • Five care plans were reviewed and found to include: 1. A resident’s profile and admission information 2. Moving and Handling Assessment 3. A Communications Report 4. Professional Involvement/Medical Visits Record 5. Weight Chart 6. Bowel Chart 7. Records of meals eaten 8. Care Plans 9. Risk Assessments 10. Care Plan Review Records 11. Accident Records • Comment cards from professional sources, two care managers indicating that her clients have care plans available and that these are always updated and reviewed. In addition to the two care managers’ comments two general practitioners and three health care professionals also remarked on the home’s care planning process, confirming that ‘specialist advice is incorporated into the service users plan’. • Staff also demonstrated an awareness of the service users’ needs and discussed their roles as ‘Keyworkers’, which on top of the hotel style services provided (keeping rooms tidy, monitoring the need for toiletries, etc.), also includes feeding back on people’s general health and social care needs and maintaining running records of the day-to-day care delivered. The awareness or understanding demonstrated by the staff for the needs of the service users, was commented on by all seven professionals, via the comment cards, one person adding: ‘staff show a very clear understanding of the clients’ needs’. • The service users also praised the staff for the care delivered, although seemed to know little about the care plans maintained on their behalf or to be interested in the content of their care plan. The evidence gathered also suggests that clients are able to access appropriate health and social care services and that the staff monitor both the outcome of such contacts and the need for further/future interventions or visits. • On arriving at the home the inspector was informed by the head of care that the manager was currently at St Marys Hospital having escorted a resident to A & E following a fall. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 12 Later into the fieldwork visit, when the manager had returned, Mrs Betteley (proprietor) arrived at the home and it was whilst being introduced to her that the inspector discovered that Mrs Betteley had taken over from the manager and remained with the service user in hospital until her condition had been assessed and continuing care needs, etc. established (which thankfully saw her return to the home later that day). In discussion with the manager she gave testimony to the fact that this is a normal practice within the service and that staff are instructed if anyone goes into hospital to contact her (if not on duty), as she prefers, due to her geographical location to meet them at A & E, etc. on arrival. • • • The care plans, as listed above, document the visits of all health, social care and medical professionals. The care planning files including evidence of the treatment plans followed re-referrals or follow up appointments. The health and social care professionals’ comment cards returned indicating that people are generally happy with the service provided to service users. The general practitioners’ and health care professionals’ comment cards, as reported above, also indicating that care plans are amended to include their treatment plans or specialist advice. • Direct feedback from service users and relatives suggests that people feel the standards of care to be high and confirmed that access to medical attention / general practitioners, etc., was appropriate. Whilst the information gathered is positive in respect of the health and social care elements of the residents’ care, the evidence gathered on the home’s management of service users’ medications found there to be failings in the system, namely an inability to maintain medication records appropriately. • During the fieldwork visit the inspector scrutinised the home’s medication system and whilst most elements of its management were found to be appropriate: Storage Checked in on receipt from pharmacist Correct disposal Individually held and/or stored medications Monitoring of medication fridge temperatures Availability of medication policies and guidance Staff training DS0000012490.V303880.R01.S.doc Version 5.2 Page 13 • • • • • • • Fallowfield The Medication Administration Records’ (MAR) were found to contain gaps where the initial of the administering staff member should appear. The failure to maintain accurate records means the document does not inform other carers or general practitioners if a medicine has or has not been given or establish why it was omitted, etc. • The two professional comment cards returned by the general practitioners and the three health care comment cards returned all indicate that people receive their medication appropriately, suggesting that it is a clerical problem and not an issue of people’s medications not being administered. Observations from the fieldwork visit day also suggest that service users receive their medications appropriately, adding further weight to the assumption that the problem is clerical in nature. The dataset also establishes that the home has a medication policy/procedure available and that again this was last reviewed and updated in December 2005. • • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 14 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): St 12, 13, 14 & 15. Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. The service users enjoy a varied, if somewhat limited social activities programme, which appears to meet their needs and preferences. The visiting arrangements at the home meet the needs of both the residents and their relatives and good community links are maintained. The service users are helped to exercise choice and control over their lives. The meals are nutritionally well balanced and appetising. The menus varied and appealing. EVIDENCE: The evidence indicates that all service users are afforded the opportunity to participate within activities and entertainments, although it is felt these are a little limited at times: • The dataset included details of the activities available generally to the clients including: DS0000012490.V303880.R01.S.doc Version 5.2 Page 15 Fallowfield 1. 2. 3. 4. 5. 6. 7. 8. 9. • Film Shows Music Quizzes and games Sing-a-longs Bingo Hairdressing Shopping trips Library Outings During the fieldwork visit the inspector observed a group game of skittles in full flow, which appeared to be enjoyed by those participating in the activity and those watching, judging by the banter and interaction. Conversations with several service users established that outings are always enjoyable occasions, although not frequent enough. A comment/observation made at the last inspection, as was the intention to arrange a visit to a local garden centre who are renowned for their Christmas decorations and exhibits, the manager during this visit also discussing the need to make plans to visit the venue. • • In conversation with a relative the benefits or merits of the activities provided were discussed, with the relative clear in her opinion that the entertainments organised had something for everyone, her relative particularly pleased at having her nails tended, as this was something she enjoyed when at home. Another relative focused on the occasional visits of the local clergy, who undertakes and conducts communion, discussing how this is a welcome event which their relative enjoys participating in. • It was also apparent during contact with Mrs Betteley that she sees her role as being one of an activities facilitator, commenting on how she takes people out and about. The evidence indicates that the visiting arrangements at the home met both the service users and/or their relatives’/visitors’ needs: • The previous inspector recording within her report that ‘Residents are welcome to have visitors at any reasonable time’. This comment was supported by the visiting inspector’s observations, with family members and friends observed arriving at and leaving the home regularly throughout the day. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 16 • In conversation with visitors it was ascertained that they are always made to feel welcome and are offered hospitality by the staff, many of whom are know by their first names. The service users also acknowledged the flexibility of the visiting arrangements and stated that they could entertain their families/friends in a variety of locations; dining room, lounge, bedroom or small lounge. Recently a service user’s relative contacted the Commission to raise concerns over the fact the small lounge or quiet lounge is also used by those clients that smoke, stating that it smelt and was unpleasant for non smokers. This issue, it was determined, had already been brought to the manager’s and proprietors’ attention, however, they believe they have done as much as they can to rectify/address the problem, introducing an extractor and keeping the room ventilated, however, the people who smoke need somewhere to go that is both safe and monitored and this is the designated facility within the home. • • • On arrival and departure from the home visitors are expected to sign the visitors’ book, this providing a degree of security and keeping track of the people in the home in the event of fire, etc. However, the log also provides evidence of the visitors to the home and the type of people undertaking the visits, relatives, friends or professionals. Examination of the home’s log demonstrated that not all visitors sign in, although where people had the picture created was of a mixed social and professional visitor group, improved use of the log would of course provide a far better view of the people visiting the home. The evidence indicates that the home’s approach to supporting people exercise their rights to choice and self-determination are good, as demonstrated throughout the report: 1. 2. 3. 4. Comments from service users in the first two sections of the report Participation in and choice of activities, highlighted above Choice of where to entertain visitors, also mentioned above Previous inspection report comments/observations In addition to the information already contained within the report the inspector also found that: • A menu is available for lunchtimes, which provides a choice of two main meal options to the service users, plus alternatives if required. DS0000012490.V303880.R01.S.doc Version 5.2 Page 17 Fallowfield • A client was observed going out on her own for a walk, however, she did initially come and inform the staff of her intention to go out and discussed where she was going and for approximately how long. The running records within the care plans document the social interaction of the service users, recording how a few of the female service users meet up in the dining room throughout the day and spend time chatting, this often going on quite late into the day/night, etc. Observations on the fieldwork visit day supported these recordings, with a number of the service users seen socialising in the dining room throughout the day. In discussion with people using both this and the main lounge it was determined that people feel generally free and able to do what they please and find none of the home’s routines restrictive or limiting (mealtime, tea rounds, etc.). One issue that did cause concern for the inspector during his visit was the home’s acceptance of the wishes of assertions of a male client, who will not close or have closed his bedroom door whilst urinating into a bottle. This particular person’s bedroom is situated along a corridor that is heavily used by other service users, staff and visitors and whilst it might be considered appropriate by some people that this gentleman’s preference/wishes be accommodated, the rights of the other service users, their visitors and staff not to observe him voiding should be considered and respected. • • • • The evidence indicates that service users are receiving a well-balanced and varied diet that is meeting their needs: • Sample menus provided to the Commission prior to the fieldwork visits and information taken from the previous inspection reports indicate that menus are ‘varied and balanced’. Although the last inspector did raise a concern around the practice of taking meals to clients in their bedrooms, etc., uncovered, which was again noticed and brought to the attention of the manager during the fieldwork visit. • Observations of the meals provided to the service users indicate that dinners are plated up according to the person’s known preference for size of meal and appetite and conversations with staff evidenced that they understand the particular eating habits of their clients. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 18 • A conversation with the cook established that menus are specifically created with the likes and dislikes of the service users in mind, although seasonal influences were of course taken into account when preparing menus. Information relating to the mealtime choices of service users are understood to be collected by care staff, with a record of the person’s choice retained in the kitchen by the cooks for reference purposes. The cook also recalled that the kitchen was visited by an Environmental Health Officer in 2004/05 and that it was stated that as no issues or concerns had been identified the home might not receive another visit for up to five years. • Records checked during the visit indicate that information about the meals chosen and consumed by the clients are available and that fridges/freezers and meals are monitored to ensure food is stored and served at the correct temperature. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 19 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): St 16 & 17 Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. Relatives and visitors are confident that complaints or concerns brought to the attention of the management are appropriately addressed. Service users are protected from abuse. EVIDENCE: The evidence indicates that generally the service users and/or their relatives are happy to raise concerns or complaints with the home and confident that the issues will be appropriately handled and addressed. • The seven professional comment cards indicating that they had never received a complaint about the home. One professional adding a remark: ‘supportive in dealing with families, who are encouraged to voice their concerns’. • Details of the home’s complaints process was included in the dataset information provided to the Commission, along with a summary of the home’s complaints activity over the last twelve months: 1. One complaint received in twelve months 2. One complaint substantiated 3. All complaints responded to within the 28 day timescale Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 20 4. All complaints resolved. Information relating to the complaints received is maintained by the home within its complaints log, along with details of the investigation and copies of the response to the complainant. • The previous inspector’s report indicated that: ‘The home has a complaints process, however, the complaints log was being updated and will be looked at at the next inspection’. As indicated above this was checked and found to be appropriate. • Information relating to the service is readily accessible within the reception/hallway of the home, making details of the complaints documentation available to service users and visitors if required. Shortly before undertaking the fieldwork visit, the Commission was approached by the family of a service user who resided at the home for a short period. The family member had clear concerns over the service delivered to her next of kin, which she had brought to the attention of the staff. During the fieldwork visit the inspector followed up on these concerns and found that the complainant had written to the service directly, following her conversation with the Commission, her concerns investigated and an outcome/response letter sent out. A little time after the fieldwork visit had been completed the Commission received correspondence from the complainant, acknowledging receipt of the outcomes of the home’s internal investigation and stating she was satisfied with the response and was not looking to pursue the matter any further. Indicating that the home’s complaints process is working effectively and efficiently. The evidence indicates that the service user’s welfare is promoted and that the management and/or staff seek to protect people from abuse and harm by their practices. • • The dataset evidences that adult protection training is being planned for staff development. All new employees are required to complete a full and detailed induction programme, which addresses all of the units defined by ‘Skills for Care’ • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 21 under the new ‘Common Induction Standards’, as evidenced by the manager during the fieldwork visit. • In discussion with staff, whilst none specifically mentioned the abuse training, it was established that the manager provides access to numerous skills development courses, the home recently creating a training / co-ordinator position to be overseen by the head of care. As already mentioned within the body of the report, relatives feel the home is meeting the needs of their next of kin and no concerns regards their safety or wellbeing was identified. Observations also demonstrate or support the belief that people feel happy and safe within the home, service users and staff interacting well throughout the fieldwork visits. The dataset also provides a clear statement of the fact that the staff are provided with access to an adult protection policy and procedure and that within the last twelve months no adult protection incidents have been referred. • • • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 22 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): St 19 & 26 Quality in this outcome area is adequate. This Judgement has been made using the available evidence, including a visit to this service. The premises is generally well maintained, clean and tidy and is a reasonably pleasant environment for the service users. EVIDENCE: The evidence indicates that the service users live within a reasonably wellmaintained, clean and tidy environment that meets their immediate and longterm care needs. • A tour of the premises evidenced that the home is clean, tidy and generally well maintained throughout. A tour of the premises was undertaken with the management, when in addition to following up on issues outstanding from the last inspection the inspector also checked the premises for continued compliance with the standards. Issues identified during the last inspection included: Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 23 1. ‘Unfortunately the sitting room carpet has suffered some damage with iron scorch marks but as the home is planning to add a conservatory to the sitting room, previous inspections said that the carpet could be replaced when this work is 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’. At this visit it was established that neither the work on the conservatory nor the sitting room carpet had been commenced, breaching the requirement set out within the last inspection report. It is imperative therefore that the manager and/or proprietors address the issue of the carpet as soon as possible, the Commission remain willing to allow the proprietors time to complete the building work on their conservatory, before the carpet is replaced, if the work required is commenced within the next three months. 2. ‘The supply of water to wash hand basins must meet the relevant environmental health & safety requirements and the needs of the individual residents’. The manager demonstrated during the tour of the premises that all hand basins and baths were fitted with thermostatic valves to control the temperature of the water delivered at source. 3. ‘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’. The manager demonstrated that she has consulted with the fire safety officer and has met with the station officers locally to discuss fire prevention and management. Notifications observed around the home and a file containing evacuation plans, etc., have also been created in association with the local officers and further evidence the work undertaken. In discussion with the manager the new ‘fire regulations’ were discussed, the manager testifying that she has addressed the risk assessment component of the new regulations. The actual tour of the premises was useful to the inspector, who had not visited the home before, as it enabled him to orientate himself to the environment and its layout. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 24 During the tour a few minor issues were brought to the manager’s attention, which would require some attention: • • A radiator/source of heating is needed within the toilet, ground floor and adjacent to the smoking room. The household/domestic rubbish/waste collecting in the rear garden must be removed. The evidence indicates that the home is clean, tidy and free from odours. • During the fieldwork visit a member of the home’s domestic staff team was observed around the home, cleaning and tidying both communal areas and individual people’s bedrooms, the work of the domestic staff team overseen by the manager. The service users spoken to praised the staff for keeping the home fresh and clean. The tour of the premises raised no concerns with regards to the cleanliness of the home or issues associated with infection or cross contamination. Polices on the above area available to staff, as are liquid soaps and paper towels in bathrooms and gloves and aprons if required. COSHH storage and the availability of data sheets was also noted to be appropriate. • • • • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 25 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): St 27, 28, 29 & 30. Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. Staffing levels are sufficient to meet the needs of the service users. The management team has achieved the target of 50 of the care staff trained to National Vocational Qualification (NVQ) level 2 or above. The recruitment and selection practices of the home are now sufficiently robust to ensure service users’ wellbeing and safety are promoted. In-house training and development opportunities for staff are good. EVIDENCE: The evidence indicates that the home employs staff in sufficient numbers to meet the needs of service users and that a comprehensive recruitment and selection, induction and training programmes are available thus ensuring that people do not work in the home unless they possess the necessary skills and/or experience to meet service users’ needs. • Copies of the staffing rosters, supplied prior to the fieldwork visits, indicate that the home is well staffed and that sufficient care staff are available, across the twenty-four hour period, to meet the needs of the service users. DS0000012490.V303880.R01.S.doc Version 5.2 Page 26 Fallowfield • Observations, on fieldwork visit day, provided further evidence of the fact that adequate care staff are available to meet people’s care and social needs, this being particularly evident during the afternoon session when the service users and staff were involved in a game of skittles. The availability of the manager or one of the proprietors to accompany service users to hospital, etc., also provides evidence of the availability of staff and effective use of resources by the management. • It was evident during mealtimes, when staff were noted to be positioned in both the dining room, as well as available to support people within the lounges and/or their own bedrooms. Service users’ families also commented on the availability and sociability of the staff describing how: ‘you never have to go looking for staff’ and thanking them for the care and attention provided during visits. The seven professional comment cards returned to the Commission also support the fact that sufficient and appropriate staff are available during the day with all comment cards returned indicating that: ‘there is always a senior member of staff to confer with’. • • Prior to the fieldwork visit the management provided details of the training completed by staff over the last twelve months, which indicated that both mandatory courses and specific training needs are being addressed: • Mandatory:Health & Safety Food Hygiene Fire safety First aid Manual Handling • Non-mandatory:Abuse/Adult Protection Palliative Care First Aid at Work Palliative care Supervision Skills National Vocational Qualifications The dataset also sets out courses the manager intends to deliver to staff over the next twelve months: • First Aid Adult Protection Health & Safety DS0000012490.V303880.R01.S.doc Version 5.2 Page 27 Fallowfield Dementia Awareness Infection Control. • The manager and her deputies also oversee the induction of all new staff and have created/purchased an induction programme that complies with the new ‘Common Induction Standards’ introduced by ‘Skills for Care’ Staff are also supported in accessing NVQ level 2 courses or equivalent, the data set returned prior to the visit indicating that the home currently has a ratio of 96 of its staff trained to or above NVQ level 2. In discussions with the staff it was established that training is both accessible and provided on a regular basis, with the management varying the times of training to encourage attendance. The records maintained by the manager were perhaps the issue that most let the home down on its training and development, as the manager has yet to introduce a training matrix or training plan, although this does not detract from the fact that training is being delivered. • • • The evidence indicates that the home’s recruitment and selection process is now being appropriately managed. • At the previous inspection the inspector noticed that: ‘three employment files were inspected and it was noted that there were some gaps in the information gathered’. At this visit it was established that only one new employee had commenced employment since the last inspection. Their file was reviewed and found to have contain: • At this visit the files of three newly appointed staff were reviewed and each was found to contain the following information: 1. 2. 3. 4. 5. 6. 7. 8. • An application form Details of interview Induction information Employment correspondents Two References Protection of Vulnerable Adults clearance Criminal Records Check outcome Supporting identification and documents The new employee was fortunately on duty during the fieldwork visit and able to confirm her previous employment history, which as listed on her application was heavily care focused, her references both coming from Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 28 her last two appointments and her experience of the induction programme, which she described as practical and useful. She also discussed being made to feel welcome when she started work and how she feels she has been able to fit into the home’s way of working (ethos), even taking on responsibility for overseeing the home’s laundry set up. • The manager also evidenced that the missing information, discovered during the last inspection visit, had been acquired and was in place on the file of the employee. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 29 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): St 31, 33, 35, 36 & 38. Quality in this outcome area is good. This Judgement has been made using the available evidence, including a visit to this service. The manager possesses both relevant care and managerial qualifications and is an experienced leader. The home’s quality assurance systems ensure the home is run in the best interests of the service users, although some internal monitoring of the staff performance is required. The arrangements for handling service users’ monies are satisfactory and designed to ensure people’s financial interests are safeguarded. The staff do not receive adequate supervision, although their practice is supervised. The health, safety and welfare of both the service users and staff team are appropriately managed and promoted. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 30 EVIDENCE: The evidence indicates that the home is well run and managed and that the service users, their relatives and staff are appropriately protected from harm and injury. • Information contained within previous inspection report indicates that the manager possesses both the National Vocational Qualification (NVQ) level 4 in Care and the Registered Manager’s Award (RMA). Evidence gleaned from the dataset and other documentation provided prior to the fieldwork visit, provides further evidence of the manager’s qualifications and experience and indicates that she regularly accesses additional courses, alongside her staff, to maintain her own skills and knowledge basis. In addition to the registered manager, the home also employs a deputy manager and head of care, the latter available throughout the fieldwork visit day and conducting herself in a professional and capable manner. In discussion with the head of care it was established that she works closely with the manager and takes key responsibility for overseeing certain aspects of the service’s day-to-day running, currently involving working with the manager on training and development. • Comments received throughout the day from residents, their relatives and staff indicate that the manager is considered to be approachable, supportive and someone who gets the job done. ‘One person stating that since she started working at the home ‘Carol’ (Mrs Montague the manager) has improved the service by addressing and resolving problems/issues’. • The professional comment cards also addressed the management of the home, all five of the health care professional and general practitioner comment cards indicating that the management ‘take appropriate decisions when they can no longer manage the care needs of the service users’. Service users and/or their relatives are afforded the opportunity to comment on the service provided at the home via the internal client satisfaction survey. This process according to the manager’s testimony is ongoing, with copies of the questionnaires accessible in house, although bi-annually all • • • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 31 service users are provided with a copy of the survey, as are their relatives who receive a copy of their survey with the fee invoice. • The home also possess a professional visitors survey, which also is available in house for completion and is routinely handed out to visiting professionals, although the manager stated to date she has yet to receive one completed professional survey back. The manager also commented on residents’ meetings, saying that these had been trialled from time-to-time but had proven unsuccessful due to the needs and wishes of the service users. Another important element of any quality auditing system is the work undertaken with the staff, which from a training and development perspective is reasonable, as evidenced earlier within the report, although improved recording practices would enhance this process further. Staff also confirmed, during conversations, that team meetings and appraisals are regular occurrences and that generally they found or considered these events useful and productive. The manager was able to provide a copy of the minutes for the last meeting when number of topics were discussed: 1. 2. 3. 4. 5. 6. • Keyworker Role Record Keeping Menu books Duty allocation board Stock Control Adult Protection • • • Supervision sessions are, according to the manager, also available to staff, the manager stating that she keeps a record in her diary of when the person’s next session is due. However, on checking through her diary the manager found that she had been missing the dates for the staff supervision and/or had forgotten to bring the dates forward in her diary, leading to a situation whereby supervision sessions were slipping to once every 10-12 weeks instead of the recommended 8 weekly. It has been suggested to the manager that a proper schedule for the formal supervision of the staff might be more effective than a diarised system, which is open to human error. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 32 Evidence from previous inspection reports suggests that no changes have occurred in how service users’ monies are managed at Fallowfield and that previously the home’s management of service users’ finances was considered appropriate and satisfactory. • The manager explaining that where the home is involved in managing the finances of service users all recommended safeguards and precautions have been adopted. This including: 1. 2. 3. 4. 5. • Obtaining receipts Double signing all transactions Balancing accounts Providing appropriate storage facilities Individually held and maintained monies/accounts. For service users wishing to handle their own monies the home will provide a lockable cabinet, etc., although the manager states that this is based on a risk assessment process, although in conversation with the residents it was clear that most people elected to have their personal allowances or monies secured by the home. This statement supported by the information contained within the dataset, which establishes that only eight of the home’s twenty-one residents handle their own finances. The dataset also indicates that the home has a policy available to staff on the management of service users’ finances and that this was last updated or reviewed in December 2005. • • The evidence indicates that the health and safety of the service users and staff is being appropriately managed. • • • No immediate health and safety concerns were identified with regards to the fabric of the premises during the tour of the premises. The dataset establishes that full health and safety policies/guidance documents are made available to the staff. Health and safety training is clearly made available to staff, with the dataset evidencing that staff complete first aid, fire safety, moving and handling, infection control and food hygiene. Access to paper towels and liquid soaps within bathrooms and toilets are indicators of attention to infection control, as is the availability of a • Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 33 specific infection control policy, as listed within the dataset and the training opportunities, as planned for later in the year. The work undertaken with the fire service, as reported earlier and the involvement of the environmental health officers, as discussed with the cook and reported earlier within the report, are also good indicators of the home’s approach to health and safety considerations. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 34 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 35 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 OP9 Regulation Requirement Timescale for action 13/11/06 2. OP19 Regulation The manager must take steps to 13 ensure medication records are accurately completed and maintained at all times. Regulation This Requirement remains 16 outstanding from the last report: 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. 13/01/07 3 OP19 Regulation The manager must arrange for 13 the domestic waste to be removed from the rear garden. 13/11/06 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 Refer to Standard OP30 Good Practice Recommendations The manager should look to implement a training matrix DS0000012490.V303880.R01.S.doc Version 5.2 Page 36 Fallowfield 2 OP36 and training plan as soon as possible The manager should produce a formalised supervision schedule for the staff. Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 37 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. Extracts may not be used or reproduced without the express permission of CSCI Fallowfield DS0000012490.V303880.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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