Inspection on 18/05/05 for Faygate House

This inspection was carried out on 18th May 2005.

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 16/06/08

Faygate House 24/05/07

Faygate House 05/09/06

Faygate House 16/11/05

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Faygate House 17 Mayfield Road Sutton Surrey SM2 5DU Lead Inspector Alison Ford Unannounced 18 May 2005 08:45 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 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 G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Faygate House Address 17 Mayfield Road, Sutton, Surrey, SM2 5DU Telephone number Fax number Email 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 9782/876 020 8643 3104 Mr Soondressen Cooppen Mr Soondressen Cooppen CRH 23 Category(ies) of Old Age registration, with number of places Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user in the DE(E) category to be accommodated. 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. Date of last inspection 18 October 2004 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. Accomodation 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 G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first statutory inspection for the year 2005/6 and was an unannounced visit. The Commission for Social Care Inspection had previously received an anonymous complaint suggesting that residents were being woken at an unacceptably early hour of the morning therefore this inspection commenced at 08.45 am. The complaint was not upheld. During the visit a partial tour of the premises, including the kitchen was undertaken, a sample of eight care plans was assessed, and all of the staff on duty, ten residents and two relatives were spoken to. The home’s owner / manager is currently in the process of training a new deputy manager who arrived during the visit. What the service does well: This home provides a clean and comfortable environment for its residents, some of whom have lived there for some years. All parts of the home and the well –maintained garden are accessible to all of them. All of the residents and relatives that were spoken to commented on the smooth running of the home and the kindness of the staff, describing them as “very polite” and “really lovely girls” One newly admitted resident, who said that she was settling in well, commented on how helpful the staff had been to her. The majority of the residents are ambulant, although some may require walking frame, and able to communicate well and express their needs and preferences. All agreed that they were always treated with respect and dignity. Several residents were happy to allow their rooms to be inspected and said that they appreciated having their own rooms, and in some cases an en-suite toilet, and being able to bring in their own possessions. Some residents explained that they like to make their own beds and help to tidy up and one lady always lays the tables for lunch. Visitors said that they were always made to feel welcome and commented on the cheerfulness of the staff. Pre-admission assessments are comprehensive and form the basis for care planning, which is reviewed regularly and documentation was well kept. Medication policies and procedures are appropriate and up to date and health and safety practices are generally of a good standard. All comments about the food that is served were favourable and all the residents agreed that they were happy living in this home. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 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 standard(s) 3,6 Senior member when undertaking pre-admission assessments on potential service users, need to ensure they are involve them in the process so that they have confidence that their needs will be met. This home does not offer intermediate care. EVIDENCE: Amongst the care plans assessed, four were pertaining to residents recently admitted to the home. All of them contained a detailed pre-admission assessment and discharges letters from hospital where appropriate. The assessments detailed all aspects of physical and social needs, medication profiles, risk assessments, dietary preferences and interests. These initial assessments form the basis of future care planning for residents and in some cases there was evidence of involvement from them as well but this was not the case for all. As the residents in this home are able to participate in this process there must be evidence in all of the care plans that this has occurred. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 9 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 standard(s) 7,8,9,10 Residents feel that they are always treated with dignity and respect, they all have an individual care plan, which is reviewed regularly to ensure that their healthcare needs remain met. Care staff when reviewing care plan need to ensure that they take ownership of the review by signing and dating it. The Home has appropriate medication procedures that protects the health needs of the service users. EVIDENCE: Eight care plans were assessed during the course of the inspection and were found to generally 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. One resident has a wound that is being treated by the community nurses. They keep their own written notes in her room, however it was recommended that a care plan outlining the progress of the wound be kept in the residents care plan. It was noted that not all of the care plans were signed and this must be rectified, with evidence of the resident’s involvement where possible. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 10 Medication records were seen and were up to date and appropriate. There is a list of those staff trained to administer medication with their signatures and photographs of the residents are on their records. A pharmacist visits yearly audits medication storage and procedures; details of these visits were available. All the residents that were spoken to praised the way that the staff in the home treated them and personal care is always undertaken in private. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 11 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 standard(s) 12,13,14,15 Service users in this home are able to exercise choice over their daily lives, the activities that they undertake and to maintain their relationships with friends and families in order to preserve their independence. The meals in this home provide choice, a balanced diet, interest and variation for the residents. 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. Visitors are always made welcome and two were spoken to during the inspection and confirmed their satisfaction with the home. 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. Residents have been encouraged to bring in possessions of their own and personalise their rooms, several make their own beds and one lady prefers to tidy her own room. Menus were seen and were varied, a choice is always offered and all of the residents that were spoken to comment on how good the food was. One resident was able to describe in great detail what was being cooked for the forthcoming lunch and food that had been served during the last few days. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 12 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 standard(s) 16, Although the complaint book was not available, the service users said that in this home they are confident that any complaints would be dealt with promptly according to the recognised policy. EVIDENCE: The complaints book was not available to be inspected it had been mislaid. All of the service users spoken to said that they would be able to raise any concerns with the staff and they were confident that they would be dealt with in a satisfactory way. One complaint had been received by the Commission for Social Care Inspection suggesting that residents were being asked to get up very early in the morning. This complaint was not upheld. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 13 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 standard(s) 19,26 The residents of this home live in a well-maintained, clean and comfortable environment, however the home cleaning needs to be carried out during the day to ensure that service users have undisturbed sleep. Fire procedures and precautions must be adhered to prevent service users being placed at risk. 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. Some door wedges were seen around the home and one bedroom door with a sprung closer did not shut fully. The maintenance man was on the premises during the inspection and agreed to rectify this and also to replace a battery, which prevented an automatic door closer from functioning. An assurance was received later that day that these issues had been dealt with and staff had been instructed to remove the wedges: this will be checked at a later visit. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 14 The home was very clean and free from malodour on the day of inspection. There was a complaint that the vacuum cleaner was used late at night. The deputy manager agreed to remind staff that all the housework should be completed in the early evening. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed at this visit. EVIDENCE: Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Service users in this home can be confident that their welfare and safety are protected in this home. EVIDENCE: This standard was only partially assessed at this visit and will be revisited at a later inspection. A tour of the kitchen revealed a clean and tidy area with appropriate temperature records and cleaning schedules being kept. Food was appropriately stored and labelled. The accident book was seen; two incidents had resulted in residents having to attend hospital. Staff were able to confirm regular fire alarm testing and a recent fire drill. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 1 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 3 Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 12(2)(3) Requirement The Registered Manager must ensure that there is evidence that service users are involved in the pre-admission asessment process. The Registered Manager must ensure that all entries in care plans are signed and dated and where feasible show the involvement of residents. The Registered manager must ensure that the complaints book is available for inspection at all times. The Registered Manager must ensure that the practice of using wedges to hold doors open is dicontinued.Where residents wish their bedroom door to remain open an automatic closer which operates in the event of a fire must be fitted. All automatic fire door closers must be fully functioning at all times. The Registered Manager must ensure that vacuuming in the home is undertaken before residents go to bed at night. Timescale for action 30/8/05 2. 8 15(1) 30/8/05 3. 16 17(2) 30/8/05 4. 19 13(4)(c ) 30/8/05 5. 6. 19 26 23(4 )(c ) 12(1)(a) 18/5/05 and henceforth 18/5/05 and henceforth 7. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 19 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 7 Good Practice Recommendations It is recommended that residents care plans contain an action plan for wound care even though a plan may have been produced by the community nurses. Faygate House G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 20 Commission for Social Care Inspection Croydon, Kingston & Sutton 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 © 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 G53-G53 S7147 Faygate House V211395 170505 Stage 0.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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