Inspection on 22/01/07 for Faversham House

This inspection was carried out on 22nd January 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

Faversham House 20/01/09

Faversham House 23/03/06

Faversham House 18/05/05

Faversham House 29/09/04

Faversham House 20/05/04

Faversham House 03/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Faversham House 59 Church Road Urmston Manchester M41 9EJ Lead Inspector Elizabeth Holt Key Unannounced Inspection 22nd January 2007 13:00 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 Faversham House DS0000006710.V309744.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. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faversham House Address 59 Church Road Urmston Manchester M41 9EJ 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) 0161 748 5998 0161 749 4915 rachel@favershamhouse.co.uk Mrs Rachel Hind Mrs Rachel Hind Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (1) of places Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 20 service users who are over 60 years of age may be accommodated. 2. A maximum of 5 service users who are below 60 years and over 50 years of age and who require care by reason of physical disability can be accommodated within the overall maximum number of 20. Date of last inspection 23rd March 2006 Brief Description of the Service: Faversham House is a care home providing nursing care and accommodation for up to 20 older people. The home is a converted two-storey property that includes a purpose built ground floor extension. There are eight single bedrooms and six double bedrooms. There are three communal toilets, two assisted bathrooms and a large ground floor shower room. The communal space on the ground floor comprises of two lounges. The home is located in the Urmston area of Manchester. There are local shops, a market and other amenities within a short distance of the home. The home is close to Urmston train station. There is a well-maintained garden to the rear of the home. There is a car park at the rear of the property. Faversham House fees range from £525.00-£600.00. There are additional charges for chiropody (private) and hairdressing. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 22nd January 2007 and a visit on the 26th January 2007. All the key National minimum Standards (NMS) were reviewed during this inspection. Information was gathered as part of the inspection process which included a questionnaire completed by the manager which gave information about the residents, the staff and the building. Information held by the Commission, for example notifications of significant incidents was also reviewed. The registered provider/manager was present during this inspection. Time was spent talking to the residents, visiting relatives, the staff team and the manager about day to day in the home and to establish what the home was like for the residents living there. A partial tour of the premises was carried out and documents and care files for a number of individual residents were reviewed. What the service does well: The provider/manager ensures that all prospective residents are properly assessed before an offer of a place is confirmed. All the staff clearly knew the residents well and had a good rapport with the residents and visiting relatives. Residents and visiting relatives were very positive about the staff in the home. One resident said, “the staff are very warm, kind and friendly.” Another resident said “The staff are patient with me and have a good sense of humour.” All the staff spoken to said that the home has a good training programme in place. The home was clean and well maintained. A programme of redecoration was in place and the bedrooms were personalised. Although the home does not have a formal programme of activities and outings residents spoken to enjoyed the activities offered and the opportunity to go on local trips out. The manager was encouraging and supportive to the staff to attend training courses and study days as appropriate. Staff records showed that the staff received regular supervision. The home has the systems and procedures in place for dealing with medication. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 6 The home had up to date fire maintenance checks, and the pre inspection questionnaire showed that health and safety checks were being carried out. The home has a system in place to find out the views from residents/relatives of what they think of the service the home provides. 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. Faversham House DS0000006710.V309744.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 Faversham House DS0000006710.V309744.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): 3 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: A completed pre–admission assessment form was seen for three residents. The registered manager carried out these assessments to ensure the home is able to meet their needs. The assessment involved the prospective resident, his/her representatives and any relevant professionals. For residents referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. Following the pre admission assessment the home confirmed in writing to the resident that the home was able/not able to meet their assessed needs. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 9 The relatives of one resident who had recently been admitted to Faversham house said “we were very happy with the process of the admission for our mother and all the staff have been very approachable and friendly”. The home did not offer intermediate care services however they have the provision for respite care for one resident. Faversham House DS0000006710.V309744.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): 7, 6, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident had an individual plan of care which set out the health, personal and social care needs of the residents. The storage, administration and recording of medication protected the residents. EVIDENCE: A sample of care plans was examined. Each care plan identified the residents’ needs and contained the information to provide guidance for the staff to provide the required care and support. There was evidence to show resident/relatives involvement in the care plans where possible. A discussion with the manager raised the need for staff to make sure the daily statements reflected the care carried out for the individual residents and reflected the nursing needs identified. Observations made during the inspection showed the staff treated the residents with respect. Residents spoken to were positive about the staff in Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 11 the home and felt they were well care for. One resident explained how some of the staff were very patient with her and she really appreciated this. Staff clearly knew the residents well and were seen and heard to be helpful and caring towards them. Risk assessments had been reviewed and evaluations of the care plans were carried out regularly. Involvement of healthcare professionals such as General Practitioner’s, Speech and Language therapist, Dietician, Physiotherapist, and Chiropodist were recorded on the residents files showing their healthcare needs were being met. The medication storage, recording and administering was checked. The medication administration records (MAR) were completed appropriately. Controlled drugs were stored and recorded appropriately. Faversham House DS0000006710.V309744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some activities were provided and residents found the lifestyle in the home matched their expectations. EVIDENCE: There was a part time activities organiser at Faversham House. Sessions with the activities organiser included arts and crafts, reminiscence and gentle exercising. The physiotherapist provided heat treatments as required and exercise classes twice a week. One resident said, “At Christmas it was gorgeous here, we had a lovely time”. The home has an open door policy for relatives which allowed them to visit at anytime. The residents were encouraged to participate in the local community where possible. Care plans included a record of social activities that had been carried out. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 13 A menu was in place which gave residents a choice of meal. Residents were consulted on their individual likes and dislikes. One resident said, “I like anything the food is great.” However another resident said, “I would like to be told what the meal is. I’ve got a delicate digestion and the sweets are really quite nice.” A discussion with the manager highlighted the need to consider writing up the main meal of the day on a display board for residents to see. Faversham House DS0000006710.V309744.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place that allow people to express their complaints/concerns. Residents are protected as staff had undertaken Adult Protection training. EVIDENCE: The complaints procedure was available and residents and relatives spoken to felt confident any concerns/complaints would be dealt with appropriately. No complaints had been received by the Commission for Social Care Inspection since the last inspection. Staff had received training in Adult protection procedures and when questioned staff were aware of the course of action to take in the event of an allegation of abuse. Faversham House DS0000006710.V309744.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a safe, well equipped environment and were clean and comfortable. EVIDENCE: The home provides a homely environment with well maintained grounds. There was evidence of a programme of redecoration. The residents’ bedrooms were seen to be comfortable and personalised with items of furniture from their own homes as appropriate. The home was well and suitably equipped with hoists, specialist beds and adapted baths. Residents who could express a view enjoyed the companionship of two kittens in the home. Odour was well managed within the home. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The numbers skill mix and training of staff was sufficient to meet the needs of the residents accommodated. Procedures for staff recruitment were in place to protect residents. EVIDENCE: On the day of the inspection the staffing numbers and the skill mix of the staff was sufficient to meet the needs of the residents accommodated. The home had recruitment policies and procedures to ensure the right people are employed to work at Faversham House. A sample of staff files were reviewed and these included application forms, written references, evidence of Criminal Records Bureau checks, induction and evidence of staff training and development. The home employs 15 care assistants with 8 members of staff having successfully completed the National Vocational Qualification 2 award. One care assistant has NVQ level 3 and two others are waiting to commence this. Staff spoken to were keen and enthusiastic about training and development to update their clinical knowledge and skills. Training in the last twelve months had included updates in Palliative Care training, diabetes, nutrition and Vulnerable adults. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 17 The staff team appeared well motivated and happy in their environment. Staff have varied and flexible shift times which the manager believes assists in keeping sickness and absences to a minimum. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home carries out her responsibilities fully. The health, safety and welfare of residents was promoted. EVIDENCE: The owner/manager is fully aware of her responsibilities and demonstrated her knowledge of the residents well. The manager has a management qualification and is well motivated to pursue academic qualifications to develop herself further. One relative said, “The manager is always kind and she is very approachable. The staff here are excellent.” Records of staff meetings minutes were available which were held quarterly. This meeting was used as an opportunity to refresh and update staff on Fire Safety and the fire drill. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 19 The home has policies and procedures in place to manage the financial interests of the residents. All the home’s policies and procedures were in the process of being updated and computerised. Procedures are in place to find out from residents/representatives what their views of the service are. The staff received regular supervision that helped them to perform their duties. This covered all aspects of practice, career development and the philosophy of care in the home. Fire safety checks were being carried out on a regular basis in line with the guidance and the last inspection carried out on the 5/07/06 showed all the fire precautions legislation were being complied with. The last Gas Safety inspection /certificate was dated 4/10/06. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 20 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 4 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 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 21 No Are there any outstanding requirements from the last inspection? 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 home should update the Service User Guide and the Statement of Purpose to include the resident groups whom the home accommodates. Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection CSCI, Local office 11th Floor Westpoint 501 Chester Road Manchester M16 9HU 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 Faversham House DS0000006710.V309744.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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