Inspection on 16/06/08 for Faygate House

This inspection was carried out on 16th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Faygate House 24/05/07

Faygate House 05/09/06

Faygate House 16/11/05

Faygate House 18/05/05

Faygate House 18/10/04

Faygate House 29/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Faygate House 17 Mayfield Road Sutton Surrey SM2 5DU Lead Inspector Barry Khabbazi Key Unannounced Inspection 16th June 2008 09:00 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 Faygate House DS0000007147.V363371.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. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faygate House Address 17 Mayfield Road Sutton Surrey SM2 5DU 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) 020 8642 9782/8762 020 8643 3104 cooppencare@yahoo.co.uk Mr Soondressen Cooppen Mrs Maleenee Cooppen Mr Soondressen Cooppen Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That bedroom 14 is registered but with an undertaking that no new residents are admitted and it is de-registered upon the departure of the current resident from that room. 24th May 2007 Date of last inspection Brief Description of the Service: Faygate House is a converted and extended residence situated in a quiet residential road in Sutton. It is currently registered by the Commission for Social Care Inspection to provide personal care for up to twenty-three adults over the age of sixty-five. Accommodation is arranged over three floors; all bedrooms are single occupancy, twelve have en-suite facilities and there is a passenger lift and a stair lift. On the ground floor there are two pleasant lounges overlooking the garden and a dining room. The home is close to local amenities and there is limited off street parking to the front of the property. At the time of writing this report the fees ranged from £426 to £450 per week. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating of the service is 1 star. This means the people who use this service generally experience adequate outcomes. All the key Standards identified throughout this report were re-assessed at this inspection. This inspection also focussed on following up on any previous requirements and recommendations, and any new issues arising. The manager’s latest self-assessment {AQAA} had only just been received by the manager and was therefore not ready to be used to support findings in this inspection. This self-assessment will however be included in the next inspection report. This inspection was unannounced. At this inspection the manager was interviewed, time was spent with the residents, and records, policies, care plans, and the building were also examined. People who use this service referred to themselves as residents. The residents made a number of mainly positive comments which included ‘It’s nice here’, ‘It’s okay here’, ‘I like the food, it’s good. It was positive to see a group of residents engaging in a group activity where most of them were smiling and laughing. The last Key inspection report contained 23 requirements. Since that time a random inspection occurred which recorded that all these 23 requirements had been met. As random reports are not published the findings of that inspection will also be included in this report. An improvement in some standards was noted at the random inspection and no further requirements were set at that time. 8 new requirements were set at this inspection, 5 of which relate to health and safety. Please see the section’ what they could do better’ for details. What the service does well: The number of care staff who have the NVQ2 qualification exceed the 50 of staff required to have this qualification by the minimum standards. This ensures a well qualified workforce. The residents appeared to enjoy the group activity observed as the majority were smiling and laughing. An immediate response to a minor maintenance concern was demonstrated at this inspection. Staff training includes training in the National Minimum Standards. This promotes a better trained workforce. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? Assessments and risk assessments are now fully completed and now also include social interests. This makes sure all a resident’s needs are known and that care is planned appropriately. Residents or their representatives are now involved in the care planning process and care plans have realistic and achievable aims. This makes the care plans more relevant to the residents and also helps ensure that staff are able to meet recorded needs. Daily records now detail how needs are met. This will make sure that appropriate interventions are used to meet need. Residents’ skin conditions are now documented more accurately. This will protect residents from harm. There is a now a clearer auditable trail of medications and residents are more clearly identified in records. This provides evidence that medications are appropriately handled and the clearer identification minimises the risk of errors. A new system of recording has been put in place to ensure that minor repairs are carried out in a timely fashion. Improvements have been made to ensure that hot water is delivered at a safe temperature. However a new minor shortfall in this area was identified at this inspection. See Standard 19. Liquid soap and paper towels are now available where staff need to wash their hands. This will minimise the risk of cross infection. Steps have been taken to eradicate the odour found in some of the bedrooms. This will make sure that residents live in a clean and hygienic home. There is now a satisfactory recruitment process in place. This will make sure that residents can be confident that appropriate staff will be employed. The Quality Assurance system has been improved {although further improvements are still needed – see Standard 33} This will make sure that residents and other stakeholders are consulted on the running of the home. Records of residents’ personal monies held in the home are now more detailed. This will help protect residents from financial abuse. The Environmental Health requirements have now been met. This will make sure that food is prepared in a safe environment. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 7 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. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 8 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 Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 9 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): Standards 3 and 6: People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known by the staff. Standard 6 does not apply to this home as it does not provide a rehabilitation service with an aim of return to the community. EVIDENCE: We looked at the previous 5 requirements under this group of standards from the last key inspection report and they had all been met by the time of the following random inspection. The file for the newest resident was examined at this inspection and all the required assessments were present and to the required standard. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 10 Standard 6 does not apply to this home as it does not provide a rehabilitation service with an aim of return to the community. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9, and 10. People who use this service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The resident’ needs are set out in a plan of care, but for the residents to be confident that all their needs are known, religious and cultural needs need to be recorded and the plans need to be more regularly reviewed. Residents’ personal care needs and physical and emotional health needs are generally met by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced can be maximised. Residents’ medication is well managed to ensure maximised good health. Residents can usually expect to be treated with respect and have their privacy upheld except where visiting medical professionals are concerned. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 12 EVIDENCE: We looked at the previous 8 requirements under this group of standards from the last key inspection report and they had all been met by the time of the following random inspection. At this inspection it was identified that some care plans did not contain any reference to religious and cultural needs. In addition some care plans had not been reviewed for 4 months. The following new requirement is now set to address these shortfalls under Standard 7: All care plans must all include a reference to religious and cultural needs and care plans must be reviewed monthly. This will ensure all a resident’s needs and changing needs are known. There were no major shortfalls identified in meeting health needs at this inspection although the following good practice recommendation is now set: Weight charts should also record action required in the event of a significant weight change. There were no shortfalls identified in medication practices at this inspection. At this inspection a district nurse came to the home to take a blood test. The deputy told the district nurse that the test could be done in the resident’s bedroom. The nurse said that it would be easier here {in the lounge}. The procedure then occurred in the communal lounge and during the procedure the container for collecting blood was dropped on the floor. As the home’s staff were seen to promote dignity and privacy in their own interactions with the residents, to be proportional a recommendation only will be set at this time as follows. To promote dignity, residents should receive medical treatment in private {not in the lounge} and staff should not allow outside medical professionals to make the decision on location for treatment on behalf of the resident. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14, and 15. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Residents experience a lifestyle in the home that generally matches their expectations. Residents are provided with opportunities to remain part of the local community and are able to take part in appropriate activities. The daily routines and the home’s policies promote the residents’ choice and rights, to ensure equality and that all rights are enjoyed by all residents. Dietary needs are catered for and a balanced diet is provided, to ensure health and enjoyment of food. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 14 EVIDENCE: The routines of daily living and activities are made as flexible as possible, for example there is no set time for finishing breakfast. Residents are encouraged to maintain social contact with their peers through an open visitors policy, and families are welcome to visit at any time, although the residents can choose who they wish to see. Representatives from a local church regularly visit the home. Two residents said they liked it at the home. There were no negative comments received at this inspection. Outings occur and activities are run by a specific activities co-ordinator. The residents appeared to enjoy the group activity observed as the majority were smiling and laughing. The home is run in a manner that promotes choice and independence and this was confirmed through residents’ comments, policies, and observation. However this does not seem to always be the case when outside professional are involved. See Standard 10 where a privacy recommendation has been set. The residents are able to take their meals the dining room, lounge or their rooms. Menus were examined and appeared nutritiously balanced and varied. A main alternative meal is available and other alternatives if neither of the two main choices are wanted. Residents have been seen to be allowed to eat at their own pace. One resident said ‘I like the food, it’s good’. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 15 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): Standards 16, and 18. People who use this service experience good quality outcomes in these areas This judgement has been made using available evidence including a visit to this service. Complaints are managed well which should ensure that residents’ and relatives’ concerns are listened to. The home’s policies and procedures help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home had not received any complaints since the last inspection. The complaints procedure was clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. The home has a Whistle Blowing Policy and a restraints policy. There is a Gifts Policy and Wills Policy. Following a requirement set another home run by the same providers, The adult protection policy had recently been amended and by the time of this inspection was in line with local adult protection procedures. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 16 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): Standards: 19, 24, and 26. People who use this service experience adequate quality outcomes in these areas This judgement has been made using available evidence including a visit to this service. The home is in very reasonably good condition externally and internally, and is decorated in a homely fashion. This creates a pleasant environment that promotes the residents’ dignity and emotional well-being. Residents’ rooms suit their needs but do not all contain all the equipment Residents are entitled to. The home is hygienic and clean, homely and comfortable; this environment therefore promotes a pleasant environment, the residents’ health, and emotional well-being. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 17 EVIDENCE: The last key inspection report contained the following 2 requirements under Standard 19: 1,The registered person must ensure that minor repairs are carried out in a timely fashion. This will make sure that residents live in a safe environment. This had been met by the time of the last random inspection. 2, The registered person must ensure that hot water is delivered at a safe temperature. This will minimise the risk of injury. This had also been met by the time of the last random inspection. However, one bedroom that was vacant did not have thermostatically controlled mixer valves. Although this also creates a minor shortfall under this standard, a requirement for this has been made under Standard 38 and will not be repeated here. See Standard 38 for details. It was identified at this inspection that not all bedrooms contained a lockable space. The following new recommendation is now set to address this: A lockable space should be available in all residents’ rooms to facilitate storage of valuables and/or medication. The last key inspection report contained the following requirement under Standard 26: Steps must be taken to eradicate the odour found in some of the bedrooms. This will make sure that residents live in a clean and hygienic home. Previous timescales has not been met. This was been met by the time of the last random inspection. The last key inspection report also contained the following requirement under Standard 26: The registered person must ensure that liquid soap and paper towels are available where staff need to wash their hands. This will minimise the risk of cross infection. This had also been met by the time of the last random inspection. However, a new requirement was needed for the same hygiene precautions for the residents’ communal toilets and bathrooms. Although this also creates a minor shortfall under this Standard, a requirement for this has been made under Standard 38 and will not be repeated here. See Standard 38 for details. Generally the building was clean and tidy and odour free. A number of other health and safety requirements that also relate to the environment have been made under Standard 38 ‘health and safety’. these also affect the rating of this group of environmental standards. See Standard 38 for details. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29, and 30. People who use this service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. The residents are supported by a staff group where 50 or more have the required qualifications. This raises the quality of staff, their knowledge and their practices. This Standard is exceeded. The current staff vetting procedure does protect residents from undesirable staff. Induction and foundation training to National Training Organisation’s specifications is in place but needs to occur for all staff. This ensures a well inducted staff group. EVIDENCE: Observations at this inspection indicated that staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. This will be examined in more detail at the next inspection. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 19 The residents are supported by a staff group where 50 or more have the required qualifications. This raises the quality of staff, their knowledge and their practices. This Standard is exceeded. Shortfalls in the recruitment process were identified at the last key inspection. The following requirement was then set to address this: The registered person must ensure that there is a satisfactory recruitment process in place. This will make sure that residents can be confident that appropriate staff will be employed. This was assessed as met at the last random inspection. Records examined at this inspection, for staff that had started since that time showed no new shortfalls. The last key inspection report contained the following requirement under Standard 30: The registered person must ensure that planned training is undertaken and implemented. This will make sure that competent members of staff care for residents. This was assessed as met at the following random inspection. At this inspection it was identified that although an induction was in place it did not meet National Training Organisation’s specifications and targets, mainly because it was not in-depth enough. It is however noted that following identifying this shortfall in the induction process at another home run by the same providers, action had already started to change the induction system. The following new requirement is now set to address this shortfall: The manager must continue the implementation of a staff induction programme that meets National Training Organisation specifications and targets. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 20 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): Standards: 31, 33, 36, and 38. People who use this service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The residents benefit from a generally well run home. The home has implemented a quality assurance system and an annual development plan, with both involving residents. This should ensure that the home is run in a way that involves the residents and a way that is in the best interests of the residents. The frequency of recorded staff supervision falls short of the minimum of six sessions required. This could affect the quality of the work that staff do. Health and safety policies and procedures need to be improved to better protect the residents. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager has suitable experience to run the home. An acting manager is also in post and they told us that the providers are considering changing the registered manager position to this individual. This will be examined in more detail at the next inspection. The last key inspection report contained the following requirement: The registered person must ensure that there is an appropriate Quality Assurance system in place. This will make sure that residents and other stakeholders are consulted on the running of the home. This was assessed as met by the following random inspection. However, it was identified at this inspection that there was no annual development plan. This is needed to collate the quality assurance information in a manner that can be presented to the residents and other stakeholders so that they can measure improvements in quality themselves. As the previous requirement was assessed as met, the following recommendation only at this time will be set: An annual development plan should be produced as a part of the quality assurance system to allow residents and other stakeholders to measure improvements in quality. We looked at the remaining previous requirements under this group of standards from the last key inspection report and they had all been met by the time of the following random inspection. Staff supervision records were examined. These fell short of the required minimum frequency. For example one staff member had no record of supervision in 2008. The following new requirement is now set to address this shortfall under Standard 36: To ensure staff are appropriately supervised, staff must receive a minimum of 6 supervision sessions in every 12 month period. Five new health and safety shortfalls were identified under Standard 38: Although thermostatic mixer valves have been recently fitted in residents’ rooms to protect from scalding, the vacant room {room 4} appears to have been missed out as there was no mixer in this rooms hand basin. The following new requirement is now set to address this: All hand basins in bedrooms must be fitted with thermostatic mixer valves to protect residents from scalding. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 22 It was identified at this inspection that communal cloth hand towels were being used in the communal toilets and bathrooms. The acting manager said this was to create a homely environment and that they were changed regularly. However cross infection will be promoted by this practice and the acting manager can not guarantee that the towels will be changed after every use as the toilets are not continually supervised. To address this shortfall the following requirement is now set: Cloth hand towels in the communal toilets and bathrooms must be replaced with a hand drying equipment that will protect better from cross infection, for example disposable paper towels or a hand blower. All of the annual testing of systems was in place although it was identified at this inspection that the fan in the conservatory was missed at the last portable appliance testing round. To address this the following requirement is now set: The fan in the conservatory that was missed at the last portable appliance testing round must be tested for safety It was identified at this inspection that there were a number of areas that contained suspected asbestos products. These were mainly in the form of plating on the inside of old doors, the most noticeable in the under stairs cupboard. If a product is suspected to be asbestos it must be treated as such until it has been professional sampled and tested. To facilitate this the following requirement is now made: To protect the residents health, the home must provide evidence, that any suspected asbestos products within the home has been professionally identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and under Health and Safety regulations. At this inspection the room that provided access to the upstairs fire escape had been blocked by furniture. In addition the fire escape stairwell itself was blocked by an old armchair. An immediate requirement would have normally been necessary, but the acting manager had these items moved during the inspection period. However, a standard requirement to stop the practices that allowed this to happen in the first place is needed as follows: Systems must be put in place to ensure that fire exits and fire escape stairwells are always kept free from obstructions. One bathroom had a lock that could not be opened from the outside in an emergency. It was seen as good practice that this lock was changed immediately to a suitable lock. This represents a fast response to maintenance concerns. Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 x x x x 3 x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 2 x 2 Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 15[2]b 12[4]b Requirement Timescale for action 15/08/08 2 OP30 3 OP36 4 OP38 5 OP38 All care plans must all include a reference to religious and cultural needs and care plans must be reviewed monthly. This will ensure all a resident’s needs and changing needs are known. 18(1)c The manager must continue the implementation of a staff induction programme that meets National Training Organisation specifications and targets. 18[2] To ensure staff are appropriately supervised, staff must receive a minimum of 6 supervision sessions in every 12 month period. 12[1]a All hand basins in bedrooms must be fitted with thermostatic mixer valves to protect residents from scalding. To protect the residents’ health, the home must provide evidence, that any suspected asbestos products within the 13[3] home have been professionally 13[4]a,b,c identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and under Health and Safety DS0000007147.V363371.R01.S.doc 15/09/08 15/09/08 15/08/08 15/09/08 Faygate House Version 5.2 Page 25 6 OP38 13[4] 7 OP38 12 23(4)b 12 8 OP38 regulations. Communal cloth hand towels in 15/08/08 the communal toilets and bathrooms must be replaced with hand drying equipment that will protect better from cross infection. For example disposable paper towels or a hand blower. Systems must be put in place to 15/08/08 ensure that fire exits and fire escape stairwells are always kept free from obstructions The fan in the conservatory that 15/09/08 was missed at the last portable appliance testing round must be tested for safety 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 OP8 OP10 Good Practice Recommendations Weight charts should also record action required in the event of a significant weight change. To promote dignity, residents should receive medical treatment in private {not in the lounge} and staff should not allow outside medical professionals to make the decision on location for treatment on behalf of the resident. A lockable space should be available in all residents’ rooms to facilitate storage of valuables and/or medication. An annual development plan should be produced as a part of the quality assurance system to allow residents and other stakeholders to measure improvements in quality. 3 4 OP24 OP33 Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Faygate House DS0000007147.V363371.R01.S.doc Version 5.2 Page 27 - 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. 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