CARE HOMES FOR OLDER PEOPLE
Fazakerley House Residential Care Home Park Road Prescot Knowsley Merseyside L34 3IN Lead Inspector
Daniel Hamilton Unannounced Inspection 21st May 2007 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 Fazakerley House Residential Care Home DS0000062027.V340008.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. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Fazakerley House Residential Care Home Address Park Road Prescot Knowsley Merseyside L34 3IN 0151 289 9203 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) Meridian Healthcare Ltd Mrs Cathrine Joan Atkinson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (30) Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. May from time to time admit up to two persons between the ages of 60 and 65 years of age at any one time Date of last inspection Brief Description of the Service: Fazakerley House is a care home that is registered to provide personal care and support for up to 30 older people, including older people with a physical disability. It has recently been completely refurbished and modernised in order to improve the environment for the people living in the home. The home is located in the Prescot area of Liverpool and is easily accessible from the M57. Local shops, bank and public transport are situated approximately half a mile away. A smoking lounge and an air-conditioned conservatory is provided on the ground floor along with the office, kitchen area, dining room and a selection of bedrooms. The upper floor, which can be accessed by a passenger lift, comprises of the rest of the bedrooms. Fourteen of the rooms are equipped with en-suites and toilet and bathing facilities are located throughout. A call bell system is fitted in all areas of the home. Care Home Fees range from £327.46 to £350.00 per week. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9.5 hours. 29 residents were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Operations Manager, Registered Manager, Deputy Manager, two care staff, one relative and seven residents were spoken to during the visit. Care Home Survey forms were also distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were assessed and action taken in response to previous requirements and recommendations from the last inspection in August 2006 was reviewed. Since the last inspection, the Registered Manager (Cathrine Atkinson) had been absent from Fazakerley House for approximately seven months. Temporary management arrangements were organised by the Registered Provider during this period, however the absence of the Registered Manager should be taken into consideration when reading this report. What the service does well:
Overall, feedback received from residents and / or their representatives was positive regarding the quality of care provided. Comments included; “The girls [Care Staff] are great. They are lovely people who genuinely care” and “This place suits me down to the ground. I feel well looked after and nothing is too much trouble.” Residents confirmed they had been able to visit the home to assess the suitability of the service before deciding to move in. One relative reported; “The manager and staff were extremely helpful when we visited the home. We found their honesty and openness refreshing.” Systems had been developed to ensure the health, personal and social care needs of prospective residents were assessed and planned for. Staff spoken with demonstrated a good understanding of the needs of residents and were observed to offer support to residents in a respectful and sensitive manner. One resident reported; “My health has improved since I arrived at Fazakerley House.” Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 6 The standard of the environment was very good. Areas viewed had been pleasantly furnished and decorated and the home was clean and tidy. Residents’ rooms had been personalised with pictures and personal possessions. A resident said; “The home is a rather nice place to live. It is very comfortable and homely.” Likewise, a relative stated; “The home is kept clean and fresh at all times.” Records showed that the home had made good progress in supporting care staff to achieve National Vocational Qualifications in Care at level 2 or above. Staff also confirmed they had access to ongoing training and development opportunities and formal supervision from their line manager. The Registered Provider (Meridian Healthcare Limited) had developed a quality assurance system to ensure the views of the people using the service were obtained periodically. Likewise, a complaints procedure had been established to ensure an appropriate response to concerns and complaints. One relative reported; “There is always someone to speak to if there is a problem.” What has improved since the last inspection? What they could do better:
Some residents and / or their representatives reported that they had not been provided with any written information on the home and / or a Contract. Prospective and current residents should have access to information on the service and terms and conditions of residency, so that they can make an informed choice about where to live. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 7 The home did not have a programme of activities and some residents lacked awareness of the recreational and social activities in the home. Feedback received from residents and their representatives via survey forms and discussion confirmed that a number of people remained dissatisfied with activities and the home’s menus. For example, comments included; “I am well cared for in the home but I would like to go out more often”; “The home provides a small selection of activities which include hairdressing, board games, cards, dominoes, quizzes and sing-a-longs” and “The food is OK but it’s nothing much to write home about.” The home should review the activities and meals provided as a matter of priority in consultation with residents and / or their advocates, to satisfy the social, recreational and dietary needs / expectations of the people using the service. The home had developed a training matrix that was not up-to-date at the time of the visit. Likewise, an induction programme had been produced for new staff, which made reference to the Training Organisation for Personal Social Services. Training records should be updated to provide accurate information on the training needs of staff and the home’s induction record should be checked to ensure it fully complies with the new ‘Skills for Care’ Common Induction Standards. All the staff working in the home had completed training in the Protection of Vulnerable Adults from Abuse however staff spoken with demonstrated different levels of understanding of how to recognise and respond to abuse. Refresher training should be provided as necessary, to ensure staff fully understand the different types of abuse and reporting procedures. Arrangements should also be made for staff to complete equality and diversity and infection control training, to ensure they fully understand the diverse needs of people accessing social care services and how to prevent the spread of infection and communicable diseases. Financial records showed that money had been taken out of some residents’ personal monies for gambling purposes i.e. ‘raffles’ and ‘sweeps’. Consent should always be obtained from residents and / or their representatives before using personal money for gambling, to protect the financial interests of residents. 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. Fazakerley House Residential Care Home DS0000062027.V340008.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 Fazakerley House Residential Care Home DS0000062027.V340008.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): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments of need are undertaken, however some people have not received the necessary information on the service, to understand their rights and responsibilities. EVIDENCE: Information on Fazakerley House had been produced in the form of a Statement of Purpose and Service User Guide. The documents had been included in an information pack and produced in a standard format for residents and / or their representatives to reference. A Contract had also been developed to outline terms and conditions of residency. At the time of the visit, the documents were not being displayed in the home and some residents spoken with reported that they had not seen and / or received a copy of the home’s Statement of Purpose and Service User Guide. Furthermore, two out of three contracts viewed had not been signed by residents or their representatives. These issues were discussed with the manager during the visit.
Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 10 The files of three residents were viewed during the visit. Each file contained a ‘Pre-Admission Assessment’ that had been completed by the home before each resident had moved in. The home’s assessment documentation was generally well constructed. The manager was advised to also consider equality and diversity issues i.e. ethnicity and gender, to ensure a holistic assessment of needs. Copies of social work assessments were also on file for residents referred through Care Management arrangements. Residents spoken with confirmed that they had been given the opportunity to visit the home to assess the quality, facilities and suitability of the home prior to admission. The relative of one resident reported; “The manager and staff were extremely helpful when we visited the home. We found their honesty and openness refreshing.” Fazakerley House Residential Care Home DS0000062027.V340008.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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based upon their individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The files of three people who had been admitted to Fazakerley House since the last visit were viewed. Each file contained a plan of care that detailed the individual health, personal and social care needs of residents and the support required by staff to achieve individual goals / objectives. Care plans had been signed by residents or their representatives and a system had been established to ensure each plan was kept under monthly review. Records confirmed that senior staff had undertaken audits of care plans periodically. Personal files also contained life history, pen picture and personal information together with a range of individualised risk assessments, daily report, medication consent forms, weight and health care records. The manager was advised to establish individualised records for personal care as the information had been grouped together for all the people living in the home.
Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 12 Health care records viewed provided evidence that residents had seen Doctors, District Nurses, Chiropodist, and Hospital staff subject to individual need. The manager reported that an Optician visited the home on an annual basis and that residents had access to Dentists as required. Feedback received from residents and / or their representatives via care home survey forms or through discussion confirmed residents had access to medical support / services when necessary. One resident spoken with said; “They help me to look after my health care needs.” Likewise, another resident reported; “My health has improved since I arrived at Fazakerley House.” Previous inspection records confirmed that the home had a copy of the Provider’s corporate medication policy and that local medication handling procedures had been produced by the manager for staff to reference. The home continued to use a blister pack system that was dispensed by a local pharmacist on a monthly basis. A record of staff authorised to administer medication and a system to check the identity of residents prior to administering medication was in place. Staff designated with responsibility for administering medication had undertaken appropriate medication training and risk assessments had been completed for residents who were selfadministering medication. Medication was stored in a locked air-conditioned room within a medication trolley. A fridge was available to store medication requiring cold storage and a daily record of temperature was maintained. Suitable storage was in place to store controlled drugs and appropriate records were maintained. Medication checked was administered, stored and recorded correctly. Records showed that all medication entering the home had been checked, signed in and dated on Medication Administration Records as previously required. The deputy manager was advised to also date medication boxes when opened, to provide a clear audit trail. Since the last visit, a new quality assurance system had been introduced, to monitor the home’s medication systems and practice. Systems were in place to account for medication returned to the pharmacist. The manager was advised to return a number of boxes containing Humulin 100IU/ml, as excessive stock levels were being maintained. Arrangements were made to reduce the stock levels during the visit by the deputy manager. Feedback received from residents and / or their representatives confirmed the people living in the home were valued by staff and that they were generally satisfied with the care provided. Staff spoken with during the visit were able to give examples of how they promoted the principles of respect, privacy and dignity in their day-to-day practice and were observed to be attentive and sensitive to the needs of the residents.
Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 13 Comments received from residents included; “The girls [Care Staff] are great. They are lovely people who genuinely care”; “This place suits me down to the ground. I feel well looked after and nothing is too much trouble” and “The staff are very good and co-operative”. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities and menus are still in need of review, to ensure the recreational and dietary preferences of all residents are met. EVIDENCE: A programme of activities could not be located at the time of the visit and some residents lacked awareness of the activities available in the home. There was no evidence to confirm that the activities programme had been kept under review with residents, as previously recommended. Since the last visit the home had stopped completing individual activity sheets and introduced an activities record book to record the details of activities and the participants. Records showed that the home provided a limited range of inhouse activities and there was little evidence of community-based activities. A minister of religion from a local Roman Catholic Church had visited the home on a monthly basis in accordance with the individual religious beliefs of residents. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 15 Feedback received from residents via Care Home Surveys and discussion confirmed that a number of people living in the home remained dissatisfied with the range of activities provided. Comments received from residents included; “I am well cared for in the home but I would like to go out more often”; “There are not enough activities. They are always inside. I would like to go out more”; “The home provides a small selection of activities which include hairdressing, board games, cards, dominoes, quizzes and sing-a-longs” and “I would like to see Sky Sports for the local matches.” Residents spoken with during the visit confirmed that they were able to receive visitors at any reasonable time and residents were observed to receive visits from family and friends during the inspection. Residents also confirmed that Fazakerley House was a relaxed place to live and that they were able to choose their preferred routines and lifestyle. Records showed that the home had not introduced a four-week rolling menu as previously agreed with the people living in the home. The home was still offering a three-week rolling menu that had been revised during September 2007. No evidence was available to confirm that the people living in the home had been consulted about the changes and one formal complaint had been received during May 2007, regarding the need for more variation in the menus. Feedback received from residents and their representatives highlighted different expectations, views and satisfaction levels regarding the meals provided. For example, comments included; “A good balanced diet is provided”; “I would like larger portions”; “The food is homely and we get a choice of meals”; “The food is OK but it’s nothing much to write home about” and; “I think the food is very good.” Menus viewed detailed that a choice of meals was generally provided to residents at each sitting and this was confirmed in discussion with residents. Meals were served in the home’s dining room at set times, however arrangements were flexible to accommodate individual needs. Additional refreshments were served throughout the day. The manager reported that the home would meet the dietary needs of current and prospective residents and demonstrated a commitment to addressing the issues highlighted in consultation with residents. Mealtimes were observed to be unhurried and care staff were observed to be available to provide assistance to residents who required support at mealtimes. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are able to express their concerns via a complaints procedure and systems are in place to protect residents from abuse. EVIDENCE: Fazakerley House had a Complaints Procedure in place that detailed that complaints would be responded to within 28 working days. A copy of the procedure was available in the reception area of the home and had been displayed in residents’ rooms. Information on the Complaints procedure was also detailed in the Statement of Purpose and Service User Guide. The home maintained a record of all concerns / complaints received. This detailed the name of each complainant, the nature of each complaint and the action taken by the manager. Records showed that three complaints / concerns had been received by the home since the last visit. Records provided evidence that complaints had been acknowledged by the Organisation and acted upon by the manager. The nature of complaints / concerns received were as follows. One concerned a resident being requested to move to a larger room due to mobility issues. Another concerned a personal care issue and the third was regarding the range of meals, the heating system and the time taken for staff to answer the front door. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 17 No complaints, concerns or allegations had been received by the Commission for Social Care inspection since the last visit in August 2006. Feedback received from residents via Care Home Surveys and through discussion confirmed that the people living in the home knew who to speak to if they were not happy and how to make a complaint. Likewise, residents reported that they felt listened to by staff and that they acted upon their comments. A relative reported; “There is always someone to speak to if there is a problem.” Policies and procedures had been developed to provide guidance to staff on how to respond to suspicion or evidence of abuse. The manager reported that all staff had completed training on abuse however some staff lacked awareness of the different types of abuse. This was brought to the attention of the manager during the visit. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment is well maintained and clean. This provides residents with an attractive and comfortable home in which to live. EVIDENCE: Fazakerley House had a part-time handyperson who was responsible for the maintenance of the home. Gardeners were hired on a contract basis to maintain the grounds. Building work was in progress at the time of the visit, to increase the size of the home. The front entrance of the home was accessible and the home was equipped with a call bell system and a passenger lift. Assisted bathing and toilet facilities were available for residents to use. Handrails were fitted along corridors and hoisting equipment was in place. Service users had personal mobility aids and grab rails were fitted in each room / ensuite, subject to individual needs. (Please refer to the ‘Brief Description of the Service’ section for more information on the premises).
Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 19 The home had been completely modernised, refurbished and redecorated during 2005, which included the replacement of all furniture and fittings. The home was suitable for its stated purpose and areas viewed were accessible, safe and well maintained. Residents’ rooms had been personalised with personal possessions and residents spoken with confirmed they were satisfied with the standard of accommodation provided. One resident reported; “The home is a rather nice place to live. It is very comfortable and homely.” Two part-time domestic staff were employed to ensure the home was kept clean and hygienic. The laundry was sited away from food preparation areas and sluicing facilities were available on each floor. Control of Substances Hazardous to Health (COSHH) data sheets and infection control policies were in place as previously noted. Residents spoken with confirmed the home was kept tidy and clean and one relative reported; “The home is kept very clean and fresh at all times.” Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are appropriately recruited and generally undertake the necessary training for their role. This protects the welfare of the people using the service and helps to develop the competence of staff working in the home. EVIDENCE: There had been no changes to the staffing levels in the home since the last visit. Three care staff and a senior carer were on duty through the day from 8.00 am to 8.00 pm. During the night, three care staff (including a senior) were on duty. The manager continued to work Monday to Friday each week. Overall, feedback received from residents and their representatives confirmed the people living in the home received the care and support they required and that staff were available when needed. Staff were observed spending time chatting with residents and offering support as required throughout the day. One relative reported via a Care Home Survey that the home had low staffing levels and that there were times when there were not enough staff to meet everyone’s needs. No evidence could be found during the visit to verify that the home had been understaffed and discussion with the manager and other staff confirmed that the home had been appropriately staffed at all times. The Organisation (Meridian Healthcare) had developed a corporate recruitment and equal opportunities policy. Pre-inspection records detailed that no new staff had commenced employment since the last visit.
Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 21 At the time of the visit the home had a vacancy for a 12-hour weekend Carer and a 16-hour weekend Cook. Two staff files were randomly selected to view during the visit. Files viewed contained all the necessary records required under the Care Home Regulations 2001. No issues of concern in relation to staff recruitment were noted at the last visit. Examination of training records and discussion with staff confirmed that staff had received induction and additional training that was relevant to their role. The manager reported that the home employed 18 care staff. Training records / certificates viewed confirmed that 11 staff had completed a National Vocational Qualification (NVQ) in Care at level 2 or above (61.1 ). The manager reported that one additional member of staff had completed the training and was awaiting a certificate (5.5 ). An additional 2 staff (11.1 ) were working towards the award. Once the remaining staff members have completed the training, 77.7 of the care staff will have attained the qualification. The Organisation had developed induction booklets for new employees, which detailed that the requirements of the Training Organisation for Personal Social Services (TOPSS) had been met. The manager was advised to review the induction package, as the TOPSS induction standards were withdrawn at the end of September 2006 and replaced with the ‘Skills for Care’ Common Induction Standards. The home’s training matrix was not up-to-date at the time of the visit. Individual staff training records viewed detailed that staff had completed a range of Safe Working Practice training, however gaps were noted for infection control training for some staff. Pre-inspection records detailed that staff had also completed additional training throughout the year that was relevant to their role. Equality and Diversity training had not been provided to staff and staff spoken with lacked knowledge and understanding of the diverse needs of people dependent upon social care services. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems have been established to ensure the home is appropriately managed and to protect the health and safety of the people living in the home. EVIDENCE: The Registered Manager of the home (Mrs Catherine Atkinson) was registered with the Commission for Social Care Inspection and had managed the home for several years. Training records showed that the manager had completed the National Vocational Qualification (NVQ) level 4 in Management, the D32/D33 care assessors award and a range of safe working practice and additional training that was relevant to her role. The manager had not been able to undertake the NVQ level 4 in Care Qualification since the last visit, as a result of being absent from work for a number of months due to personal reasons.
Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 23 The manager confirmed that it was her intention to register and complete the award as a matter of priority, to ensure she had the necessary qualifications for her role. Residents, staff and visitors spoken with reported that they were happy to see the manager return to work following a period of absence. The manager demonstrated a clear sense of direction and leadership for staff to follow, to ensure effective outcomes for the people using the service. Evidence was available on staff files to confirm staff received regular formal supervision from senior staff and this was confirmed in discussion with care staff. Records showed that the Operations Manager had continued to undertake regular visits and produce a monthly report in accordance with Regulation 26 of the Care Home Regulations 2001. Minutes were available to confirm that two ‘Residents Meetings’ had been coordinated since the last visit. The manager was advised to develop a standardised agenda, in order to develop the content of meetings with the people using the service. A Residents / Representatives survey had been completed during July 2006 as previously noted. This involved distributing questionnaires to residents or their representatives to seek their views on a range of issues. 21 (70 ) of the thirty questionnaires distributed were completed and returned. The outcome of the survey indicated that satisfaction levels were consistently high across all sections of the survey, with the majority of the results falling in a range between ninety to one hundred per cent. Social activities and events were rated slightly below the average level at seventy seven per cent as noted in standard 12. The manager reported that the service was in the process of distributing questionnaires / survey forms to seek feedback for the next annual survey. The Organisation’s head office was responsible for invoicing residents or their representatives for fees and a system was in place to enable payments to be made by standing order. The manager did not act as an appointee for any of the residents, as the people living in the home received support to manage their finances from either family members or personal representatives. Records showed that the home looked after the personal finances for 23 residents. Records were checked for three residents. Transactions had been recorded and receipts had been obtained for expenditure. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 24 Records showed that money had been taken from some resident’s personal monies for “Sweeps” and “Raffles”. The manager was advised to obtain consent from residents and / or their representatives and to ensure a clear audit trail for all money used for gambling purposes. Previous inspection records detailed that the Provider had developed a Health and Safety Policy for staff to reference. Pre-inspection records detailed that services and equipment within the home was regularly serviced. Fire records were viewed during the visit. The records showed that the fire alarm system had been tested on weekly basis and that monthly checks on the fire extinguishers and emergency lighting had been completed. Service records were in place to confirm the home’s fire safety equipment had been maintained. A fire risk assessment had been completed and staff had received regular inhouse fire drill / instruction training. Insurance, Gas safety and lifting equipment service certificates were also viewed and found to be up-to-date. Discussion with staff and examination of training certificates confirmed staff had completed basic in-house training in the majority of Safe Working Practice topics as part of their induction and ongoing training. Records showed that some staff required infection control training as identified in Standard 30. Risk assessments had been produced since the last visit for Safe Working Practice topics including ‘Catering’, ‘General Cleaning’ and ‘Care Practices.’ Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations A copy of the Statement of Purpose and Service User Guide should be made available to each resident and displayed in the home, to provide information on the service provided. Copies of Contacts should be made available to people before admission to the home and copies on file should be signed, to confirm residents and / or their representatives are aware of their rights and obligations. Pre-admission Assessments should be updated to include information on equality and diversity issues including ethnicity and gender. A programme of in-house and community based activities should be developed and kept under review in consultation with residents, to satisfy the social, religious and recreational needs of all the people living in the home. The home should consult residents on the development of the home’s menu, to ensure the dietary preferences of
DS0000062027.V340008.R01.S.doc Version 5.2 Page 27 2 OP2 3 4 OP3 OP12 5 OP15 Fazakerley House Residential Care Home 6 7 8 9 10 11 OP18 OP30 OP30 OP30 OP30 OP35 residents are taken into consideration. Staff should receive refresher training in the Protection of Vulnerable Adults to ensure they understand how to recognise and respond to abuse. The home’s training matrix should be updated to provide information on the training provided to the full team. The Organisation’s induction documentation should be reviewed to confirm it meets the requirements of the ‘Skills for Care’ Common Induction Standards. Staff should complete Equality and Diversity training to ensure they fully understand how to recognise and support the diverse needs of people accessing social care services. All staff should complete infection control training to ensure they understand how to prevent the spread of infection and communicable diseases. Consent should be obtained from residents and / or their personal representatives, before using residents’ personal monies for gambling purposes, to protect the financial interests of residents. Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Fazakerley House Residential Care Home DS0000062027.V340008.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
