Inspection on 23/03/07 for Fanshawe

This inspection was carried out on 23rd March 2007.

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

Fanshawe 13/11/08

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

CARE HOMES FOR OLDER PEOPLE Fanshawe 53 Hooe Road Hooe Plymouth Devon PL9 9QS Lead Inspector Mandy Norton Unannounced Inspection 23rd March 2007 10:00 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 Fanshawe DS0000068105.V331424.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. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fanshawe Address 53 Hooe Road Hooe Plymouth Devon PL9 9QS 01752 481663 01752 482775 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) R.M.J.J. Healthcare Ltd Mrs Deborah Elizabeth Anne Watts Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability over 65 years of age (23) of places Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23.02.06 Brief Description of the Service: Fanshawe is situated in Hooe, Nr Plymstock, near to local shops and on a bus route. Originally a Victorian house it has been modernised and extended. The accommodation comprises of 11 single bedrooms and 6 double rooms over 2 floors. There is a passenger lift providing access to both floors. The communal areas are on the ground floor and comprise of a homely lounge, a small lounge adjacent to the dining room and a conservatory/sun lounge. There is access to a small patio area with seating provided. The home provides nursing and personal care to a maximum of 23 people, over the age of 65, male and female, with physical disability and /or frailty. The home has recently changed hands and is owned by Mr Bassett T/A as R.M.J.J Healthcare Ltd. The manager remains the same. The home provides a comfortable friendly atmosphere, people are encouraged to furnish their rooms as they choose, and each room is individual in its character. The Statement of Purpose is due to be reviewed and the deputy matron was advised to include information about how a person who cannot visit the home or does not have access to the internet can get a copy of the inspection report. She was also advised that the last inspection report should be available at all times in the entrance foyer. The fees range from £450 - 585 (as of March 2007). The contracts examined show the total fee but not a breakdown of what makes up the fee (such as the funded nursing care contribution), the provider said that this will be added to the contracts to enable people to understand exactly who is paying what. Contracts are issued to every Service User whether they are publicly or privately funded. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 11.15 am until 15.15 pm on the 23rd March 2007. The inspection was carried out with the deputy matron and the owner present. A brief tour of the home was carried out. The report contains views from 12 care workers surveys reflected throughout, information taken from the completed pre inspection questionnaire and discussion with staff on the day of the inspection. Service Users seen were not always able to fully express themselves or comment on the care they received. What the service does well: Fanshawe is homely, comfortable and welcoming. There was a calm atmosphere during the inspection with staff interacting well with the people living in the home. The information about the home given to prospective Service Users and or their representatives has sufficient detail to allow an informed decision to be made about moving into the home. When possible, prior to admission, the matron visits the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home peoples needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. The processes in place protect the health and welfare of the people living in the home such as the complaints procedure and health and safety procedures. People are able to maintain contact with family and friends and exercise choice and control over their lives. People living in the home receive a wholesome appealing diet. Alternatives to the menu are always available. The home presented as clean and hygienic. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Fanshawe DS0000068105.V331424.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 Fanshawe DS0000068105.V331424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. The home is not registered to provide intermediate care. EVIDENCE: Pre admission documentation examined included information about peoples assessed needs, medications, next of kin and general information about the person. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 9 A brochure that includes the Statement of Purpose is given or sent to every person wishing to move into the home. The deputy matron was advised that the last inspection report and Statement of Purpose should be displayed in the entrance foyer and information included in the Statement of Purpose about how people who cannot visit the home or access the internet can get a report. The home is not registered to provide intermediate care Fanshawe DS0000068105.V331424.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager promotes and maintains peoples health and ensures access to health care services to meet assessed needs. The homes medication systems protect the welfare of Service Users. People are treated with respect and their right to privacy is upheld. EVIDENCE: Three (3) care plans were examined; in all of those seen there were assessments which provided information about skin integrity, moving and handling, safety - including risk of falls, use of bed rails risk assessments and nutritional screening. The information generates the plans of care, which provide the basis for the care to be delivered. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 11 The care plans were clear and easy to understand and had been regularly reviewed. The carers complete a ‘routine functions’ chart, included in the care plan, to indicate the general care that has been given to the person concerned. There is also a hand over book that any comments are made that need passing over to the next shift to come on duty. Comments from a number of completed carers surveys indicated that the care plans were ‘good’, ‘comprehensive’ and ‘excellent’. Two (2) of the eleven (11) completed carers surveys indicated that the routines are ‘very rigid’ and people living in the home should not ‘fall into’ the homes routines. Records are maintained for all visits to the home by social or health care professionals, all residents are registered with a GP. Records in care plans detailed outpatient appointments and GP visits showing that health resources are enabled to use health resources. The medication system is well managed; storage of the drugs trolley, controlled drugs and the drugs fridge are in a small treatment room; the staff have managed well with this limited space over the years. Regular ordering and monitoring of medicines ensures no over stocking of medicines and dressings. Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Effort is made by the home to provide an activities programme and social interaction/stimulation for Service Users. People are able to maintain contact with family and friends and exercise choice and control over their lives. People generally receive a wholesome appealing diet and are not rushed. EVIDENCE: The pre inspection questionnaire submitted prior to the inspection lists a range of activities that take place in the home including – cards, skittles, various entertainers and church services. People living in the home can go out with their relatives and friends if they are able to. One (1) completed care workers survey said that staff do ‘free time’ activities well. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 13 The menus provided with the pre inspection questionnaire are on a rolling programme and include the diabetic options for dessert. People can eat their meals in the dining room or in their room if they wish. On the day of the inspection a number of people were being assisted in the dining room. It was noted though that at least 2 people were having trouble eating the choc ice that they had been given, they were not able to pick it up and couldn’t manage to get the spoon into it either. The suitability of some of some of the foods presented to the less able people or those with a degree of dementia was discussed with the deputy matron. The cook was not spoken to during the inspection or the kitchen records examined as it was lunch time. The records have been found to be satisfactory in the past. The kitchen is small and a new fridge had been purchased that was found to be too big for the space allocated. It was therefore plugged into the conservatory until the space had been made bigger. The inspector was assured that this was a very short - term measure. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives/friends are well informed and know how to make a formal complaint. People are safe living in this home. EVIDENCE: The complaints procedure was seen displayed within the home and is in the Statement of Purpose/ brochure (due to be reviewed), given to all Service Users and /or their representatives prior to admission. The pre inspection questionnaire states that there have been no complaints or adult protection referrals sine the last inspection. Ten (10) of the eleven (11) completed care workers surveys indicated they were aware of adult protection procedures One (1) completed care worker survey said it would be useful to meet with the matron individually to air any grievances. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is safe and generally well maintained and clean and hygienic ensuring the people living in the home live in a satisfactory environment. EVIDENCE: A brief tour of the home showed that peoples rooms contained personal items including furniture, ornaments and pictures that reflect their personality and interests. The home has 2 lounges, a conservatory/sun lounge and a dining room. The conservatory had a large fridge in it during the inspection. The deputy matron explained that it was new and when it arrived it was found to be too large for Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 16 the space allocated for it. The inspector was assured that this was a very short-term arrangement. The home appeared well equipped to meet the needs of people identified with moving and handling risks and disabilities that affect their ability to bathe, although two (2) of the careworkers surveys said that the manual handling equipment is old and not well maintained and is ‘always breaking’. One commented that some of the rooms are small making moving and handling difficult at times. Some specialist mattresses and adjustable beds were seen in place for those people requiring them. The provider said that more adjustable beds are being purchased with the aim that all beds will be adjustable. There is call bell system throughout the home. There were a variety of toilet facilities for use by Service Users throughout the home. There is a shaft lift between both floors. Hand washing facilities were seen throughout the home as were protective gloves and aprons. The home has limited storage space but it looked clean and generally tidy during the inspection. The laundry is located separately from the home and is large enough to manage the amount of washing produced. The kitchen is small and narrow. When in use the serving trolley has to be stored in the corridor out side the kitchen. The catering staff manage well with the facilities they have. The home looked generally well maintained during the tour of the premises, this is supported by the information supplied in the pre inspection questionnaire about dates of servicing of equipment (03/06) and fire equipment checks (28.09.06) for example. The new provider said that a programme of redecoration and refurbishment has been started and showed the inspector one room that is being done whilst it is empty. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with appropriate skills and knowledge to meet most of the needs of the people living at the home. The homes recruitment procedures protect people living at the home from being placed at risk of harm or abuse. EVIDENCE: The duty rota supplied with the pre inspection questionnaire shows that for 20 Service Users there is a trained nurse on duty 24 hours a day supported by 5 carers in the morning, 5 in the afternoon and early evening and 1 overnight. The care staff are supported by catering, domestic and maintenance staff. During a tour of the home staff were engaged with residents and there was a calm and organised atmosphere. Training records are kept with individual staff files and included fire safety, first aid and infection control. NVQ (national vocational qualification) training is ongoing for a number of staff and the number of care staff already qualified to level 2 NVQ is 50 . Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 18 Four (4) of the completed care workers surveys indicated that they are asked to ‘care for people outside their area of expertise’. During the tour of the home it was apparent that there are a number of people with a degree of dementia. It was recommended that the staff, including catering staff (see standard 15), are offered some training in this area of care. Some of the completed surveys state that the people living in the home are ‘well cared for’ and ‘cared for as individuals’. New members of staff are recruited following a formal application to the home, after references, Criminal record checks and an interview has taken place. Staff files examined had all of the required documentation included in them. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced Registered Nurse. The informal quality assurance system in place ensures the people living at the home and /or their representatives are asked about what it is like living in the home. Personal money held in the home on behalf of people is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of people living at the home and the staff. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 20 EVIDENCE: The matron was on sick leave at the time of the inspection (CSCI are aware) so the deputy matron is running the home in her absence. The new provider lives locally and is on hand if the staff have any concerns. He was available throughout the inspection. The home has its own complaints procedure and the pre inspection questionnaire indicated there had been no complaints or adult protection referrals since the last inspection. The need for future robust systems of quality assurance were discussed with the deputy matron. Many of the completed care workers surveys stated that there are no formal staff meetings and it would be good if there were. The deputy matron said that there is a handover between staff at each shift change where changes/ developments with people who live in the home are discussed. Staff supervision and appraisals are overdue as the manager is on sick leave. The deputy matron said that she is aware that it is one of the matron’s priorities when she returns to work. (These records will be checked at the next inspection). Safety notices were displayed throughout the home including action to be taken in case of fire. The completed pre inspection questionnaire indicates that all equipment is regularly maintained and tested. PAT testing stickers were seen on electrical equipment throughout the home. The fire and accident book were examined and found to be completed as required. The staff accident book conforms with the latest data protection requirements. Best practice systems are in place for the safe handling of peoples money; all receipts are stored for auditing purposes and the money is stored securely. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X 3 3 3 3 3 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 3 3 3 X 3 X X 3 Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations The Statement of Purpose should be reviewed and updated to reflect the recent changes within the home and include information about how the last inspection report can be accessed by people who cannot visit the home or have access to the internet. The last inspection report should be available in the entrance foyer at all times. The contracts issued should include a breakdown of the fees to be paid. People living in the home should be offered food that they can manage either by picking it up or by being able to cut into it and manoeuvre it around the plate. Training offered should equip the staff to meet the changing needs of the people living in the home. Staff meetings should be held regularly to ensure staff are updated about changes and important information and to DS0000068105.V331424.R01.S.doc Version 5.2 Page 23 2 3 4 5 OP2 OP15 OP30 OP32 Fanshawe allow for an exchange of ideas. Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Fanshawe DS0000068105.V331424.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!