Inspection on 05/09/06 for Faygate House

This inspection was carried out on 5th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Faygate House 16/06/08

Faygate House 24/05/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Faygate House 17 Mayfield Road Sutton Surrey SM2 5DU Lead Inspector Margaret Lynes Key Unannounced Inspection 5th September 2006 10:30 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.V307626.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.V307626.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 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.V307626.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. 16th November 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.V307626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of almost seven hours and consisted of examination of documentation in the home, a tour of the premises and discussion with service users and staff. All of those who kindly assisted the Inspector during the day are thanked for their efforts. The previous inspection of this home had resulted in three requirements. Of these it was deemed that one had been met, but that further work was required to meet the other two. This inspection has resulted in a further 16 requirements being made, and 9 good practice recommendations. A considerable number of these relate to relatively minor premises matters and as such they should not be difficult to meet. As the manager was not present, an additional visit will have to be made to the home to examine staff recruitment, training and supervision records. Evidence to support the comments below was gathered from a range of sources – the service users themselves, relatives, members of staff and inspection records. What the service does well: What has improved since the last inspection? What they could do better: The two requirements that were outstanding and had still not been met at the time of this visit related to the need to ensure that a copy of the pre-admission assessment of residents was available for inspection, and to ensure that the Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 6 complaints book provided details of any action taken in relation to a complaint, and also the outcome of complaints. The new requirements relate to the need to improve service user plans, health care documentation, the number and variety of available activities for service users, medication administration, some policies and procedures, maintenance of the building, fixtures and fittings, risk assessments and the frequency of fire drills. 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.V307626.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Having examined the files of six service users, including three who had been placed in recent months, it was still not possible to evidence that the home was carrying out a pre-admission assessment before agreeing to admission. This means that it is feasible that the home may agree to accept a client whose needs they are unable to meet. EVIDENCE: Of the six files examined, none of those relating to recently placed service users contained a pre-admission assessment. This was somewhat of a surprise, given that a requirement to this effect had been made in the last inspection report. Had these files contained an assessment from the placing Authority, then matters would not be of so much concern, however none of them contained this information. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All but one of the service user files examined contained a plan of care. This means that in relation to that one exception, it is difficult to see how staff can ensure that all aspects of the individual client’s can be met. While the records relating to health care needs were being maintained, there was little to evidence that staff were following up on issues such as notable weight gain/loss of some service users, or acting upon requests made by colleagues. This means that service users health needs are not being fully met. The majority of the medication administration records were in order however there were some errors noted. Any errors with regard to medication can, potentially, have serious consequences for service users. As mentioned in the summary at the beginning of this report, the vast majority of service users commented very positively with regard to the way that they were cared for, and felt that their privacy and dignity was maintained. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 10 EVIDENCE: The one file that did not contain a service user plan related to one of the newest admissions. While it is accepted that a long-term care plan may not have been drawn up in the short period that this client had been at the home, it is expected that an interim plan would have been put in place, and this plan would be based on the pre-admission assessment. Unfortunately, this file did not contain any pre-admission assessments either. Most of the care plans that were examined were being reviewed monthly, although there were some gaps in this process. From the records it appeared that several clients had, at some point, either gained a notable amount of weight over a 1-month period, or had lost a notable amount. While staff had been diligent in recording these weight changes, there was no evidence that further investigation and action had taken place. There was no mention in the daily notes and nothing to suggest that, for example, advice had been sought from a dietician or the GP. It was also noted that on occasion a member of staff had requested her colleagues on the next shift to pay particular attention to certain health issues relating to specific clients, as the carer had had some concerns. There was nothing to evidence that other staff had acted upon these requests. More detailed and thorough recording of concerns and the action taken to resolve them is therefore needed. Just one unsigned box was found on the medication charts. It was also noted, however, that on one occasion staff had used Tippex and also that a considerable number of the charts did not have a photograph of the service user attached. While a photograph does not necessarily have to be attached to the medication chart, one for each service user is required to be on file, and the most logical place for it is with the aforementioned charts so that staff have no difficulty in identifying residents. It should be added that there were no photographs (where they were not with the medication sheets) in the main service user files either. Staff should maintain a record of medication returned to the pharmacy. There was a book entitled medication returns, however it was being used for other purposes. All of the service users spoke with were positive about the staff team and the way that they were cared for. One raised some concerns regarding choice, which will be referred to in the next section. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 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 the following standard(s): 12-15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. From discussion with service users, it appeared that they were enabled to maintain contact with family and friends and to some extent the community. There were mixed views with regard to recreational activities, and it is felt that the home needs to do more to evidence that it is meeting service users needs in this regard. Most of the residents were happy with the food provided. EVIDENCE: Although the Inspector spent most of the day in the home, there was no evidence of any organised activities. When asked, a number of the service users stated that they had little to do, and found life in the home somewhat boring at times. When activities were organised, they found them enjoyable. Some also commented that they would like to go out of the home for a walk, but that they had been specifically told that they could not go out. While it is reasonable to ask service users not to go out alone, if a risk assessment has indicated that their safety may be compromised, staff must then ensure that time is made to escort those who wish to go out. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 12 Only one service user commented negatively, as they felt that one member of staff had treated them like a child and refused to offer them a choice as to when to bathe. The same service user was more than happy with the overall care provided however. Menus were seen and were varied, and a choice is always offered. It is again recommended that the chef should spend some time talking with residents to monitor their preferences and satisfaction with the food, as comments regarding the quality of food were mixed. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users in this home felt that any complaints would be dealt with promptly, and there was a satisfactory policy and procedure in place. Improvements are still needed, however, to the recording of complaints. There was also a satisfactory adult protection procedure which, if followed, should ensure that service users are safeguarded from abuse. There is a need for the home to have a policy and procedure with regard to restraint however. EVIDENCE: Following the last inspection it was required that the complaints record be improved so that there was a clear record of any investigation taken, and the outcome of it. At this visit it was not felt that appropriate changes had been made, as the two entries that had been made since the last inspection visit were incomplete. The home has a copy of the Local Authority multi-agency adult protection procedure to supplement its own in-house policy and procedure. The home received one allegation that staff had mistreated residents earlier this year. This was investigated and the allegation could not be substantiated. A policy/procedure regarding the use of restraint could not be found and it is required that one is drafted made available to staff. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 14 Due to the unavailability of staff files, it was not possible to determine how many staff had attended training in adult protection. This will be looked at at the next visit. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house has some beautiful original features and while 6 requirements have been made it was nevertheless felt that the service users were living in a safe, comfortable, clean and largely well-maintained environment. EVIDENCE: As mentioned above, some of the original features of the building have been retained, making it an attractive home, particularly the dining room. Almost all of the building was inspected, and a number of relatively minor areas identified for repair/attention. With the exception of two of the bedrooms, where there was a noticeable odour, the home was found to be commendably clean. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None It was not possible to assess compliance with these Standards as the staff files were unavailable for inspection. A further visit will be made to ensure compliance. EVIDENCE: Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is some uncertainty as to whether the registered manager (who is also the proprietor) wishes to continue in that role, or appoint a replacement. While this uncertainty has not, as yet, impacted upon the service users, it is beholden on the proprietor to make it clear who is in day-to-day control of the home. Due to a number of gaps in the health and safety documentation it was not felt that the health, safety and welfare of service users and staff was being as well promoted and protected as it could be. EVIDENCE: The registered manager is also the proprietor, however it was noted at the last inspection that the bulk of the manager’s role was being undertaken by the Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 18 deputy, who was receiving training commensurate to this work. This deputy had now left, and it is unclear who is undertaking the day-to-day running of the home. Although on the rota, the manager was not present on the day of the inspection. A decision must therefore be made by the proprietor as to whether he wishes to remain as the registered manager, and thus commit the bulk of his working day to the home, or appoint a replacement. It was not possible to inspect the quality assurance systems (re key Standard 33), as the relevant documentation was not available. This will, therefore, be assessed at the next visit. None of the service users have their finances looked after by the home (re key Standard 35) – this role is undertaken by either their family, advocates or placing Authority. The maintenance records were examined and it was found that there were a number that were either out of date or could not be found. These included maintenance checks relating to portable electrical equipment, gas safety, electrical installations, the assisted bath and the stair lift. The record of checks of the temperature of bath and basin hot water was not up to date, while a current waste disposal contract was not available. There was a detailed health and safety risk assessment on file but unfortunately it had not been reviewed since 2002. A brief assessment had been conducted in 2005, and a review date for 2006 had been set. There was no evidence that the review had been conducted however. Where staff identify issues that need immediate attention, they record their concerns in a specific Issues for Immediate Attention book. This is good practice however it would be helpful if it could also be recorded what action was taken with regard to each entry and when. The home has taken action to comply with the previously made requirement regarding the recording of fire drills and an appropriate book in which to record these drills is now being kept. This showed that only one drill had taken place this year – this frequency must be improved. A number of doors had had door guards fitted so as to allow them to be kept open. It was noted though, that there remained a number that were wedged open. If it is felt that these need to be open, then the appropriate fire safety closure devices must be fitted. While touring the building it was noted that there were a number of emergency call bell cords that had been tied up to keep them out of the way. All such cords must be untied and within easy reach of service users or staff. A check of the accident book indicated that a minority of the residents had suffered from a number of falls. It would be good practice to carry out an analysis of these falls to determine if there is any proactive action that could be taken to reduce such occurrences. Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 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 3 X X X X X X 2 Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 20 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 OP3 Regulation 14(1)(a) Requirement The Registered manager must ensure that a copy of the preadmission assessment of residents is available for inspection. The Registered manager must 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 ensure that all service users have an individual plan of care. The Registered manager must ensure that health care records are more accurately maintained and that where action is needed/taken, this is documented. The Registered manager must ensure that medication records are accurately completed at all times and that there are photographs of service users available. A medication returns book should also be maintained. The Registered manager must ensure that there are an adequate number of activities for DS0000007147.V307626.R01.S.doc Timescale for action 01/10/06 2. OP16 17(2) Schedule 4 15 12, 13 01/10/06 3. 4. OP7 OP8 01/10/06 14/09/06 5. OP9 13 14/09/06 6. OP12 16 31/10/06 Faygate House Version 5.2 Page 21 7. OP18 13 8. OP19 16, 23 9. 10. OP19 OP19 23 16 11. 12. 13. 14. OP19 OP26 OP26 OP38 23 16 23 13 15. OP38 13 16. OP38 23 17. OP38 13 18. OP38 23 service users. The Registered manager must ensure that there is a policy/ procedure in place re the use of restraint, and that staff are familiar with it. The curtain in bed 26 must be re-hung, the seat in the en-suite WC repaired and a lampshade fitted. There must be regular cleaning of external windows in service user bedrooms. All lights must be fitted with an appropriate lampshade – there were a number around the home without. A new window opener must be fitted in bedroom 16. Steps must be taken to eradicate the odour found in two of the bedrooms. Cleaning staff must ensure that all extractor fans are regularly cleaned. The Registered manager must ensure that all maintenance checks are up to date, and that this can be evidenced. All staff must ensure that emergency call bell cords are untied and within easy reach at all times. Where it is wished that fire doors are kept open, then they must be fitted with a suitable fire safety closure device. The Registered manager must ensure that periodic health and safety risk assessments of the premises are carried out, recorded, and reviewed. The Registered manager must ensure that fire drills are carried out quarterly and that one of these includes the night staff. 31/10/06 01/10/06 01/10/06 01/10/06 01/10/06 01/10/06 01/10/06 01/10/06 14/09/06 31/10/06 31/10/06 31/10/06 Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 22 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 3 4 Refer to Standard OP7 OP9 OP11 Good Practice Recommendations It would be good practice to ensure that all care plans are reviewed monthly. It would be helpful for staff if an up to date BNF could be purchased for the home. It would be good practice to ensure that the wishes of all residents in the event of their serious illness/death are recorded. Staff should ensure that they discuss beforehand with service users how and when they plan to carry out certain aspects of their personal care – such as bathing, so as to avoid any confusion and/or conflict. It would be good practice to periodically discuss the menu with service users, and incorporate their preferences and requests. The door to bedroom 19 would benefit from being oiled. The chipboard underneath the WC (WC near to office) is stained and unsightly and a replacement is recommended. It would be helpful if staff could indicate when and what action is taken to meet the issues recorded in the Issues for Immediate Attention book. It would be good practice to carry out an analysis of the number of falls suffered by service users to determine if there is any proactive action that could be taken to reduce such occurrences. OP14 5 6 7 8 9 OP15 OP19 OP26 OP31 OP38 Faygate House DS0000007147.V307626.R01.S.doc Version 5.2 Page 23 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 © 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.V307626.R01.S.doc Version 5.2 Page 24 - 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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