CARE HOMES FOR OLDER PEOPLE
Favordale Favordale Byron Road Colne Lancashire BB8 0BH Lead Inspector
Mrs Marie Dickinson Key Unannounced Inspection 7th February 2008 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 Favordale DS0000035216.V357566.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. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Favordale Address Favordale Byron Road Colne Lancashire BB8 0BH 01282 860449 01282 866749 Debbie.Watson@careservices.lancscc.gov.uk 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) Lancashire County Care Services Miss Deborah Margaret Watson Care Home 44 Category(ies) of Dementia (14), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (3), Old age, not falling within any other category (30) Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 44 service users to include: Up to 30 service users in the category OP not falling into any other category Up to 14 service users in the category (DE) Within the total number of OP registered places, three named service users who fall into the category MD(E) may be accommodated 31st July 2007 Date of last inspection Brief Description of the Service: Favordale is registered with the Commission for Social Care Inspection to provide personal care and accommodation for forty-four people. The home is owned by Lancashire County Council and managed by Lancashire County Care Services. The property is a purpose built building, set back off the main road, with gardens to the side and rear. There is a central courtyard accessible to the residents. Accommodation offered is in single bedrooms. Some have en suite facilities provided. There are sufficient bathrooms and toilets, and various aids provided for residents to maintain independence throughout the home. The home is divided into two units for people requiring residential and dementia care. The residential unit is on two floors. The upper floor can be accessed via a passenger lift. Both units have lounge and dining areas. The home is staffed twenty-four hours a day, with a member of the management team on duty and on call at all times. Information about the service is available from the home for potential residents in a Statement of purpose and Service User Guide. Weekly charges for personal care and accommodation range between £342 and £392 per week. Residents are responsible for additional extras such as newspapers and toiletries. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
A key unannounced inspection was conducted in respect of Favordale on the 7th February 2008. This is the second key inspection carried out within the past twelve months. The inspection involved getting information from an Annual Quality Assurance Assessment completed by the manager, staff records, care records and policies and procedures. It also involved talking to residents, staff on duty, the manager, and an inspection of the premises. Written comments from relatives and residents were received giving their view of the service provided. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Older People. One additional visit had been made to the home in December 2007. This visit was in relation to monitoring compliance of legal requirements relating to resident care. What the service does well:
New residents had their needs assessed, before a placement in the home was offered. Records showed they were consulted about the level and type of care they required. Important information needed to support them in every day living was recorded and used to establish if Favordale could provide the right care and support. Residents living in the home benefited the support of a named worker referred to as a Key worker who took responsibility to make sure care needs for individuals was personalised. Residents also benefited additional specialist support where needed that included health and mental healthcare need. Staff caring for people with dementia had training in this specialist area of work. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 6 Throughout the inspection there was overall opinion staff were very caring. Comments were made such as ‘they are very good’, and ‘caring’. Relatives thought the care staff were lovely’. They were made to feel welcome and ‘all the staff care for residents in a proper and caring way 100 .’ And ‘staff are very good and my mother is quite happy’. Residents were supported to keep in contact with relatives and friends. Adult protection was given a high profile with staff training and contractual arrangements to protect residents. Written comments from the manager showed a ‘zero tolerance’ with poor practice. Accommodation for residents was good. The home was tastefully decorated and furnished to a high standard. Aids required to assist people to be independent was provided. Gender issues were considered by having a male carer. The training provided for staff was very good. Staff interviewed showed they had good knowledge in understanding the needs of older people. Systems were in place to approach residents/relatives to give their view on the quality of services and facilities in the home. Small amounts of money held on behalf of residents were managed well. What has improved since the last inspection?
An action plan had been taken by senior management to improve medication practice and procedures. To make sure staff recognise symptoms to administer ‘when required’ medication prescribed by doctors, this was recorded in more detail, particularly when people are unable to tell someone. Resident’s supervision when given medication had improved. Arrangements had been made to allow people visiting the home some comfort whilst waiting to be given access to the home. This was by having access to sheltered seating in the homes entrance. Supervision and assistance given to residents on the dementia unit had improved, enabling residents to receive adequate nourishment during meals. The weight loss of residents was being monitored, with risk assessments completed and action plans do deal with people considered at risk. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 7 What they could do better:
People using the service must be provided with clear information about the actual level of fees charged and details about the arrangements for paying the fees, within the contract. All residents care plan must detail all the needs of the resident, including their healthcare needs. This is to provide staff with clear information about how best to meet, monitor and respond to these needs and help residents to be cared for as they wish and require. Plans must be reviewed properly in order for residents changing needs to be considered. To make sure residents are not placed at risk, for example poor sleep patterns and associated needs, and potential aggression, management of these risks must be available to inform staff. Residents’ dignity must also be considered by making sure there is enough staff available at all times to attend to their personal needs. Activities for residents must improve and take into account their wishes to enable them to have a lifestyle experience suitable to their needs. Arrangements must be made to allow people visiting the home easier access within a reasonable time span. The overall provision of meals served must improve and provide residents with wholesome, and nourishing diet that meets with their needs and expectations. Issues of concern raised by residents must be taken seriously to enable them to have confidence in using the complaints procedure. Some residents in the dementia unit are confused with the patterned carpet. Consideration should be given to replacing this with a plain carpet. To prevent bedrooms from having an unpleasant smell, cleaning should be more frequent. Sufficient staff must be employed to make sure the safety and welfare of residents is considered at all times and their needs are properly met. Requirements made to comply with regulation must be dealt with in a satisfactory manner. Systems should be in place to monitor practice and compliance with plans, policies, and procedures and make sure the home is run in the interest of residents. Supervision of staff should be given regular.
Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 8 This will help staff develop professionally and improve caring skills. Staff meetings should be held frequently to support them in their role as carer. Staff should also have questionnaires provided by the Commission given to them, enabling them to express their views as to the service they provide and support they receive. Views of residents and staff made to the management must be taken into account to support people influence the service provided. 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. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 9 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 Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 10 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): 2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contracts issued, informed residents about the terms and conditions of living at the home, which meant they knew what was included in the costs, however some residents were not informed of their cost for staying at the home. Assessments were completed properly which helped plan personalised care. EVIDENCE: Records showed that new residents in the home had their needs assessed before they were admitted. People had an assessment from social care and an
Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 11 assessment carried out by a representative from the home. Both assessments showed essential information was recorded to provide staff with sufficient information about the resident’s circumstances and level of support required to give the right care. They included for example, personal care, and physical and mental health wellbeing. Comments sent to the Commission from residents and information recorded on the pre inspection assessment completed by the manager for the last key inspection, showed that not everyone had been issued with a contract. This was in relation to privately funded residents who had signed an agreement to pay the higher rate in fees. These were not identified on this agreement. Information available during this inspection showed that this issue had not been dealt with for these residents. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 12 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 adequate This judgement has been made using available evidence including a visit to this service. Care plans written for residents helped staff to provide personal care for them. However some shortfalls in linking needs to planned support meant resident’s needs were not always fully dealt with. Resident’s healthcare was monitored and medication was managed safely. EVIDENCE: Since the last key inspection there had been some improvement in care planning for residents. The format used was good in that it identified need, action to be taken to meet needs, frequency, and person responsible. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 13 Completing these for the benefit of residents and staff still required further development. Linking care planning to essential needs must show a planned support programme. For example, supporting continence management. And management of ‘disturbed sleep’ recorded in resident’s notes that potentially linked to weight loss and created a need for additional nutritional support. There was also need for better indicators for management of aggression. To ‘encourage to keep as much independence as possible, but due to mental health problems this is often difficult’ was recorded, however the difficulties and abilities of residents were not clear. Improvements made included better recording for general risk assessments and in the overall management of people at risk of poor nutrition. There had been improvements also in working towards a person centred approach to care planning. Care plans were being reviewed. Residents had a night care plan that showed how care was to be provided during the night. Relatives, who sent written comments for the inspection, thought they were usually kept informed of matters that involved their relative. Although the number of staff available in the dementia unit had increased, residents in the residential unit considered the poor staffing levels meant they had to wait for essential support such as getting up or being assisted to the toilet. Written comments received at the Commission from relatives included ‘low staffing levels and some over demanding or inappropriately classified residents mean occasional problems with care.’ Residents interviewed also spoke of problems getting staff support when needed; ‘Sometimes there is only one on duty, which means people like me needing assistance can’t get to the toilet when they want.’ Several residents related the needs of others accommodated in the residential unit, exceeded the limit of staff time available, stating ‘it was an utter disgrace the way things were’. Staff had access to training in health care matters and those staff caring for people with dementia had training in this specialist area of work. The aims and objectives of the home clearly show the importance of treating individuals with respect and dignity. Residents thought staff in the home was mindful of their privacy when giving personal care. There were policies and procedures and practice guidance, for staff responsible for medication administration. The home operated a monitored dosage system for the administration of medication, which was dispensed into controlled dose packs by a local pharmacist. Medication records were fully completed. An organisational action plan had been introduced which helped management ensure the safe administration of medication and reduce the risk of any error being made. Staff responsible for handling, recording and administering medication had been trained. Favordale DS0000035216.V357566.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. 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. Staff worked hard in difficult circumstances in an effort to meet the needs of residents. Social, recreational activities did not consistently meet with every resident’s expectations. Catering arrangements were not satisfactory to meet individual need. EVIDENCE: Residents who sent written comments to the Commission for this inspection gave a mixed opinion as to their daily life within the home. They considered support given to live the lifestyle they chose was compromised through a lack of staff availability. Comments included, ‘As well as can be expected, but not enough staff,’ and ‘they have no time to talk, one mad rush’. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 15 Relatives also had mixed views. ‘All the staff care for residents in a proper and caring way 100 .’ ‘Staff are lovely but overworked.’ And ‘the staff don’t have a lot of time to do anything with residents and it must be difficult for them, trying to cope with the demands and keep people happy.’ Residents choice in relation to daily living was observed. People were up for the day at different times and residents said there were no rules imposed on them such as, when they went to bed or got up in the morning. However residents in the residential units considered this did not always go to plan as there were not enough staff available to help them in essentials ‘let alone anything else’. Residents considered staff gave them as much time as they could but said they were ‘run off their feet’. There was some evidence of daily activity in the dementia unit, and residents were observed knitting, doing a jigsaw and reading. An aromatherapy session was held for those residents wishing to pay for this service. Staff were also observed spending time with residents chatting to them and taking an interest and joining in with what they were doing. An additional member of staff employed meant this was possible. A record of residents’ interests and preferences was held on their assessment, although this could be better linked to a person centred care plan, to ensure these needs were not overlooked and were person specific for everyone. Visiting arrangements were good and several residents talked about their family visiting. Staff made visitors welcome. Arrangements were made for residents to have meetings. Comments from residents about the food indicated there had been no improvement since the last inspection. Some residents said the food was ‘cold’. And meals were at times ‘disgusting’. Several examples were given. Written comments regarding meals included ‘recently some has been revolting’, and could do with a ‘better budget for the food ingredients and provide better and tastier food’. One relative questioned whether ‘a sausage roll and gravy’ was considered a substantial meal. Staff were observed offering support to those people who could not manage to eat their meal without assistance. The additional staff support on the dementia unit had improved the level of support residents required was provided. The cook said menus were discussed with the residents, and choices were offered. Menus in use showed alternatives to choose from. Records had not always been maintained to show what had been provided when the menu had been changed and what each resident had been served. The actual meal served during inspection was not the same as the menu plan. The meal served looked substantial and offered choice. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 16 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 adequate This judgement has been made using available evidence including a visit to this service. Residents had access to a robust complaints procedure, however this was not always applied satisfactorily, which meant residents had little confidence in using it. There were policies and procedures, and appropriate training for staff in professional conduct and adult protection issues. This meant residents rights, and welfare was promoted. EVIDENCE: There had been no complaints raised formally to the Commission since the last key inspection. Written comments from residents indicated there was a general understanding of the complaints procedure and although one response was ‘they didn’t need it’, another response as to action being taken was ‘yes’ but ‘subsequent action is minimal’. Most residents knew whom they could speak to but several said there was no point keep raising their concerns as ‘no one took any notice’. One remark was made of being ‘victimised’ for raising issues. The circumstances were unclear and during the inspection referred to the manager to deal with. Most residents however said they had no complaints against the staff in general.
Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 17 Staff working at the home said they were trained in adult protection and were aware of the abuse policies and procedures, which included whistle blowing. Staff confirmed they had regular contact with the area manager of Lancashire County Care Services and could approach her with any problem. Staff contracts precluded them from financial reward or assisting in or benefiting from the service users’ wills. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 18 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): 19,20,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, warm, comfortable, well-maintained, safe environment that suited most of their needs. EVIDENCE: The home is divided into two units, residential and dementia. Entrance to the home and dementia unit is by keypad access. This can be difficult to access as
Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 19 staff and management dealing with residents needs are not always available to answer the bell within a reasonable time. Visitors to the home can however wait in an enclosed seated area whilst waiting. The patterned floor covering in the dementia unit was observed to cause some confusion for residents. A smoking area has been designated to comply with Government regulation. Residents have not been offered a choice, or risk assessed to smoke in their own bedrooms. The manager said this was not being considered. Residents were satisfied with their bedrooms. Some thought the cleaning schedules had been reduced. A random check of bedrooms identified two bedrooms with an unpleasant smell. Overall the home was found to be reasonably clean and fresh smelling during inspection. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 20 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 poor This judgement has been made using available evidence including a visit to this service. The level of staffing in the residential unit was not satisfactory to meet the needs of residents. Recruitment procedures were good and protected residents. Staff were trained to care for residents safely. EVIDENCE: The home was staffed in accordance with the requirements of Lancashire County Care Services. Rotas were kept of the staff deployment in the home. These showed as identified in the last key inspection, there continues to be periods of time in the day where there is a shortfall of staff numbers required. Whilst staffing levels in the dementia unit had improved shortfalls were identified in the residential unit. Observations made during the inspection showed a diverse range of needs of people accommodated on the residential unit who required ongoing support and supervision. Staffing numbers did not match with these needs. Staff were observed to have to spend significant time working together to hoist specific residents leaving others without staff support.
Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 21 Residents in the home also expressed concern of the ‘shortage of staff.’ They said staff didn’t have time to deal with situations that arose. Comments suggested ‘carers were not reporting incidents that were happening such as residents shouting and swearing’, it’s ‘very unfair’. One person said a resident was ‘continually coming in and standing at the side of her bed’. Another resident said she was ‘frightened of one resident, who took her personal items’. Written comments received at the commission in regards to the staffing levels supported this general feeling of lack of staff presence on the units. People considered that to improve the service ‘better staffing levels’ was required. ‘Low staffing levels and sickness means casual staff are sometimes left to work alone. Sometimes they struggle’. Equally staff were described as ‘lovely but overworked’. The manager said additional hours had been allocated to ease the situation to benefit the residents. This would start on the following Sunday. There had been no new staff employed and this standard was not assessed. The last key inspection showed good recruitment practice was carried out. This included all essential recruitment checks required by regulation to be complete, prior to employment. In addition to induction training, all staff were trained in essential mandatory training such as moving and handling. Senior staff were also trained in medication administration. The percentage of staff having completed NVQ level 2 and above was over 50 . All employees had other training. Specialist training in dementia care was provided. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,36,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home was not always run in the best interests of residents. The health and safety of residents and staff was considered, however more attention was required to ensure the diverse needs of residents were considered in the event of an emergency. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 23 EVIDENCE: The management structure of the home consists of the registered manager and assistant managers who maintain a management presence in the home at all times. The manager is experienced and holds recognised management and care qualifications to be in charge. Part of the role as manager is to work within the boundaries and expectations of the corporate business plan and budget for the home. Lancashire County Care Services as Registered Provider have overall responsibility. Senior management visit the home unannounced every month, looks at records, interview staff and residents, and send a report of this visit to the Commission. In response to requirements made at the last key inspection, the area manager had spent time in the home to audit residents experience, staff performance, and management skills. A report was sent to the Commission of the improvements that were being made. Not all requirements made at the last inspection have been addressed to a satisfactory conclusion. There was evidence the residents are informed of the running of the home. Residents meetings are regular and company policies and procedures are discussed with them. Residents spoken to and written comments received at the Commission showed that there was some degree of ‘no confidence’ in raising concerns. Written comments included, ‘Inspectors have already enquired, but no improvement. Everyone is now complaining and wanting to move elsewhere.’ Lancashire County Care Services aims are to promote equal opportunities for staff and residents. Staff meetings were normally held, however there was a general feeling of ‘the management at senior level were not listening to what they were saying about the strain of having to manage with limited staff and high dependency needs of the residents’. Evidence available showed there was inconsistent supervision of staff with infrequent individual sessions and few staff meetings. A questionnaire issued by the Commission had not been distributed to the care staff. The manager said they had been placed in a clear view folder in the staff room. Staff interviewed was not aware of these. Relationships between staff and those living in the home were observed as positive and residents openly praised the staff, which they considered had their welfare at heart. The manager must take more responsibility to make sure monitoring of practice and compliance with the plans, policies, and procedures of the home is efficient. Insurance cover was in place to meet any loss or legal liabilities. The home encouraged residents/relatives to manage their own financial affairs. Residents who are able manage their own finances continue to do so. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 24 The health, safety, and welfare of residents and staff had been considered. The home had a good range of policies and procedures and practice aimed at keeping everyone safe. Risk assessments to support residents and staff health, safety, and welfare however must be completed to take into account planning the care and diverse needs of residents, such as an emergency evacuation. Written working procedures and training opportunities were available to support development of good care practice. Essential mandatory training is periodically renewed. Information received at the Commission for the last key inspection indicated that essential services such as gas and electricity were regularly serviced. Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 25 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 2 X 2 Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5(b)(c) Requirement People using the service must be informed in writing of the cost of staying in the home. Previous timescale of 26/10/07 Not met Residents care plans must include all identified needs and provide clear detailed instructions for staff, on how to meet these needs. The plans must be kept under review and revised accordingly with the involvement of the residents. Previous timescales of 01/09/06 and 14/09/07 not fully met Risk assessments must be completed showing how to manage, reduce, or eliminate potential risks. Previous timescales of 01/09/06 and 14/09/07 not fully met. Suitable arrangements must be made to ensure the dignity of residents is respected by sufficient staff being available to attend to personal needs at all times. Previous timescales of 01/09/06 and 26/10/07 not
DS0000035216.V357566.R01.S.doc Timescale for action 31/03/08 2. OP7 15(1)(2) 31/03/08 3. OP7 13(4)(c) 31/03/08 4. OP10 12(4)(a) 31/03/08 Favordale Version 5.2 Page 27 5. OP12 6. OP15 7. OP16 8. OP27 9. 10. OP32 OP33 fully met Improvement in activities and lifestyle for residents must be improved, individually and as a group. Previous timescales of 31/03/06. 29/09/06 26/10/07not met. 16(2)(i)12 Residents must be provided with (1)(a)(b suitable, wholesome, and nutritious food, which is varied and available as required. Previous timescale of 01/09/06 and 14/09/07 not met. 22 Complaints made by residents must be taken seriously and responded to according to the homes complaints procedure. 18(1)(a) Lancashire County Care Services must employ sufficient staff to meet the diverse needs of residents. Previous timescale of the 30/04/06, 29/09/06, and 26/10/07not met. 12(5) Views of residents and staff must 21 be taken seriously. 10(1) Areas where improvement is required must be responded to within the timescales given by the Commission. Previous timescale of 26/10/07 not met. 16(2)(m)( n) 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 28 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. 2. Refer to Standard OP13 OP19 Good Practice Recommendations Arrangements should be made for visitors to enter the home in a timely manner. It is recommended the patterned carpet in the dementia unit be replaced with a plain carpet to support residents who are unable to differentiate between a pattern and something on the floor to be picked up. It is recommended cleaning of bedrooms improve to avoid a build up of unpleasant odours. It is recommended supervision of staff and regular staff meetings is kept up to date. It is recommended an effective, accountable system be in place to monitor practice and compliance with plans, policies, and procedures. Risk assessments for safe practice should include care and routine of the home. 3. 4. 5. 6. OP26 OP36 OP32 OP38 Favordale DS0000035216.V357566.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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