CARE HOMES FOR OLDER PEOPLE
Faygate House 17 Mayfield Road Sutton Surrey SM2 5DU Lead Inspector
Alison Ford Unannounced Inspection 16th November 2005 11:00 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.V265264.R01.S.doc Version 5.0 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.V265264.R01.S.doc Version 5.0 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 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.V265264.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 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. A variation has been granted to allow one specified service user in the DE(E) category to be accommodated. 18th May 2005 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. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second statutory inspection for the year 2005/6 and was an unannounced visit. During the visit, a partial tour of the premises was undertaken and a sample of four care plans was assessed. During the last inspection the majority of the standards, considered by The Commission to be key to the inspection process, were assessed and a large proportion of this visit concentrated on talking to residents in order to gain their views of living in the home. The Commission has received no complaints about this service since the last inspection and this report should be read in conjunction with the one produced following that inspection on 18th May 2005. What the service does well: What has improved since the last inspection?
All of the concerns raised at the last inspection have now been addressed. Care plans now contain evidence that residents and their relatives have been involved in their compilation and they agree with the level of support and intervention that is being provided. A complaint had previously been made about staff using a vacuum cleaner at night. The deputy manager now undertakes spot checks of the home at various hours and is confident that this has now stopped. Residents in the home also confirmed this.
Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 6 Care staff are now being encouraged to undertake their NVQ training and were able to explain how it was improving their practice, particularly with regard to respecting residents dignity and recognising abuse. 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. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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 Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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): 3,6 Service users in this home have a comprehensive pre-admission assessment provided by their care manager, however, there is no evidence that potential residents can be assured that the home will meet their assessed needs. This home does not offer intermediate care. EVIDENCE: Four care plans of residents admitted to the home since the last inspection were seen. All of them contained a detailed pre-admission assessment from a care manager and discharge letters from hospital where appropriate. The manager of the home undertakes his own pre-admission assessment; these have been seen before, however they were not present in these care plans. They must be available for future inspections in order to show how it is perceived that the home will be suitable for the assessed needs of the resident. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 9 Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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): 7,8,10 Residents feel that they are always treated with dignity and respect and they all have an individual care plan, which is reviewed regularly to ensure that their healthcare needs remain met EVIDENCE: Four care plans were assessed during the course of the inspection and were found to be in good order. All residents have an individual care plan, which is based on their initial assessment. It includes risk assessments and details how residents should be supported with their personal care needs. Skin integrity and nutritional requirements are assessed regularly and visits from other members of the multidisciplinary healthcare team are documented. There is evidence that residents and their relatives have been consulted about the content of these plans. All the residents that were spoken to praised the way that the staff in the home treated them. They commented on “how kind” and “genuine” staff were.
Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 11 Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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): 12,15 Service users in this home are able to exercise choice over their daily lives in order to maintain their independence. Not all residents consider that the meals in this home are suitable for their needs. EVIDENCE: A range of activities suitable for this client group is provided however residents explained that they could choose whether or not to participate. Some prefer to watch television or read. Some residents explained that they liked to get up early in the morning and watch television; others preferred to stay in their beds until a little later. Some adverse comments were received about the choice of food served in the home however the majority of residents did not support this view. Menus were seen and were varied, and a choice is always offered. It is recommended that the chef should spend some time talking with residents to monitor their preferences and satisfaction with the food.
Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 13 Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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): 16,18 Service users in this home are confident that any complaints would be dealt with promptly, according to the recognised policy, and that they are safeguarded from abuse. EVIDENCE: The complaints book was inspected and a small number of issues had been raised both by residents and staff. In future this record should include details of the investigation undertaken, any action taken and the outcomes. Staff demonstrated that they were aware of actions to be taken should they suspect abuse of residents is occurring and the deputy manager stated that new staff are not employed without the necessary pre employment checks being completed. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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): 19,26 The residents of this home live in a well-maintained, clean and comfortable environment, which suits their needs. EVIDENCE: This home is situated in a pleasant quiet road and is fully accessible to all its residents via a passenger or stair lift. There is a programme of maintenance and decoration and the ground are kept tidy, safe and attractive. All the communal areas are appropriately furnished and well lit and service users have been able to personalise their bedrooms. The home was very clean and free from malodour on the day of inspection. There had previously been a complaint that the vacuum cleaner was used late at night however this practice has now ceased. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 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): 27,30 Residents in this home are cared for by well-trained and competent staff who are able to meet their assessed needs. EVIDENCE: On the day of the inspection staffing numbers were in accordance with those previously agreed and the off duty rotas were seen. Staff are being encouraged to study for NVQ level 2 qualifications and one was able to explain how this had influenced their practice and improved outcomes for residents. One new member of staff had been employed since the last inspection however their staff file was not available. An assurance was given that all necessary checks had been completed and arrangements will be made to see this at a later date. Statutory training had all been undertaken and it was suggested that the home should compile a training profile to make it easier to identify any areas that need to be addressed in the future. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 17 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): 31,33,35,38 Residents are confident that they live in a well managed home where their welfare and safety are protected and their views are taken into consideration so that they feel valued. EVIDENCE: The Registered Manager is a trained nurse and has been in post for some time however his deputy undertakes much of the day-to-day management of the home. She is undertaking appropriate training in order to fulfil this role. A quality assurance audit is in place in the home and regular residents meetings take place in order to monitor their views and satisfaction with the services that they receive. The home does not take responsibility for the finances of any of the residents in the home, all of them have someone who is able to support them. A selection of certificates of worthiness of equipment were seen and were up to date apart from confirmation of this years portable appliance testing. The
Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 18 deputy manager was certain that this had been done and will forward a copy of the certificate to The Commission. A new fire alarm panel has recently been fitted and is tested weekly. Regular fire drills are held; dates of theses must now be recorded. Food hygiene practices were recently assessed and all of the recommendations have been complied with. Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 19 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 20 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 OP3 Regulation 14(1)(a) Requirement Timescale for action 30/01/06 2. OP16 17(2) Schedule 4 17(2) Schedule4 3. OP38 The Registered manager must ensure that a copy of the preadmission assessment of residents is available for inspection. The Registered manager must 30/01/06 ensure that the complaints book also provides details of any action taken and the outcomes of any complaints that are made. The Registered manager must 30/01/06 ensure that there is a record of fire drills, undertaken in the home, available for inspection. 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 OP15 Good Practice Recommendations It is recommended that the chef should meet with residents on a regular basis to ascertain their views of the food served in the home.
DS0000007147.V265264.R01.S.doc Version 5.0 Page 21 Faygate House 2 OP30 It is recommended that there should be a training profile compiled illustrating the training undertaken by each member of staff Faygate House DS0000007147.V265264.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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