Inspection on 05/09/05 for Fessey House

This inspection was carried out on 5th September 2005.

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

Fessey House 06/11/07

Fessey House 01/05/07

Fessey House 13/11/06

Fessey House 06/12/05

Fessey House 14/12/04

Fessey House 28/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Fessey House Brookdene Haydon Wick Swindon Wiltshire SN25 1RY Lead Inspector Stuart Barnes Unannounced 5 6 and 19 September 2005 th th th 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. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fessey House Address Brookdene Haydon Swindon Wiltshire SN25 1RY 01793 725844 01793 706104 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) Swindon Borough Council Doreen Nicholls Care Home 40 Category(ies) of OP Old age registration, with number of places Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Any person outside the category of Older People who are receiving care and accommodation at the home as at 30th October 2003 may remain living in the home, subject to an assessment or review of their needs at least every 6 months that the home is able to satisfactory meet their care needs 2 When the home has a vacancy after 1st April 2004, this vacancy must not be filled until such times as the home is able to recruit the full time equivalent of 18 care staff in substantive posts. Any such calculations must not include staff employed solely designated to work in the day care facility, the home manager and ancillary staff such as administrators, cooks, cleaners, housekeepers and gardeners. 3 Full time is defined as working 37 hours per week. 10 December 2003 Date of last inspection 14 December 2004 Brief Description of the Service: Fessey House is a large care home owned and managed by Swindon Borough Council. It is located in a quiet cul de sac in the Haydon Wick area of Swindon. There is easy access to the local shops and a community centre. The home is on 2 floors and is sub divided in to 4 living areas. Three of these living areas provide long term social care and accommodation. The other area provides respite and crisis care on a short term basis. Each living area has its own separate lounge and dining room with a kitchenette where drinks and snacks can be prepared. The main meals (typically lunch and tea) are cooked in a central kitchen. Other meals are prepared in the living units. All bedrooms are single rooms and can be decorated to the occupant’s choice. Service users are encouraged to personalise their rooms and may furnish them with their own furniture. Typically there are 7 or 8 care staff on duty plus a shift leader or manager. At night 3 care staff work in the home. Additionally the home deploys a housekeeper in the mornings at busy times in each living area as well as providing cleaning staff. Designated staff are employed to carry out administrative and cooking duties. If the home is short of permanent staff it relies on staff working extra hours or agency staff. On the same site there is a local day centre that is run by Age Concern. Some service users can attend the day centre if there is a vacancy and they meet the criteria. The Commission does not inspect the day centre as it has no powers to do so. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that the term service user and resident used throughout this report are interchangeable. Since this inspection was completed and this report written, the home has been registered for 43 people. This inspection was carried out over 3 days. The first day was unannounced, the other 2 by arrangement. On the first day, time was spent with the deputy manager progressing the requirements and recommendations of the previous inspection, examining various policies and checking various documents. On the 2nd day time was mostly spent talking to service users and staff on duty as well as examining a sample of case documentation. The views of a relative were also obtained. On the 3rd day, time was spent with the registered manager, checking the arrangements for staffing the home, interviewing staff and giving feedback. In total 20 out of 36 National Minimum Standards (NMS) were inspected. Matters referred to in this report that arise from how staff are deployed in the mornings and where the respite care service is located will be dealt with by amendment to the current conditions of registration. What the service does well: What has improved since the last inspection? There has been a reduction in the amount of agency staff working in the home. The new manager is being more successful at not admitting people whose needs cannot be met at the home. Some improvements have been made in the way care is planned. A start has been made on developing a quality assurance questionnaire and getting the views of the service users. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 6 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. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.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 Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.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) 1, 2, 3, 4 and 5 The Home provides good information about the services it provides. There are concerns that the service is not adequately meeting all the needs of the people who live at the home. There appears to be a lack of understanding of what an assessment of need means. Daily records are improving. The standard of assessment varies. EVIDENCE: The inspector was shown a recently updated version of the homes statement of purpose and the service user guide in a draft format, ready for publication. The service user guide is available in large font on request. There are plans to record the service user guide on audiotape. Examination of a sample of case files shows that each service user has been issued with a written contract/terms and conditions of residency. Where appropriate relatives are provided with copies of these documents and asked to sign them on behalf of service users. Terms and conditions for people on respite care do not give enough detail. Some of the people living at the home have been assessed prior to admission as needing residential care but on closer examination these documents do not fulfil the criteria of assessing a persons needs. Some of the documentation Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 9 tends to describe desired outcomes more than assessed need. There are examples where the assessment documentation gives insufficient attention to a person’s history of falls and to their health care needs including any preventative needs. For example, one person with type 2 diabetes had no dietary preferences included in her written assessment or had any identified needs associated with them being registered as blind. One of the senior staff members on duty told of their concern that the risk assessment in relation to a person who falls needed to be done more often. Senior staff also made comments that there was insufficient time to give to assessment, care planning and review. Though some of the assessment documentation is muddled discussion with key staff indicates that they know their residents well. However this is not a substitute for proper documentation, which is needed when key staff change and when residents move to other care settings. There is evidence that shows that people seeking a place can undertake a preplacement visit and that they are encouraged to stay over night as part of the admission process. There is also evidence that relatives are encouraged to view the home to meet key staff as part of the pre- placement plan and to gather relevant information to help the person settle. The home keeps a ‘record’ on each service user that details key information, key events or any change of circumstances that arise. The quality of these records varies depending on who writes them. For example there is evidence of sensitive recording of difficult issues and good attention to the day-to-day care needs in some documentation. Some documentation has missing information such as contact addresses for the person’s social worker and the address of the GP. Some care plans were undated and some information is not sufficiently detailed or clear as to its meaning. The documentation for one recently admitted person showed contradictory information, which was not adequately explained. It included a diagnosis of medium to severe dementia which if correct is a condition which the home is not able to meet their needs. Another staff member said the lack of good teamwork meant that the care was not as good as it could be. Staff report concerns about not having enough time to attend to peoples needs. Not withstanding these concerns, when the manager undertook a quality assurance survey no service user reported back any negative comments about the way their care needs were being met. Elsewhere in this report there are examples that illustrate times when staff appear to congregate in small groups leaving service users unattended for short periods. There was no evidence to show that the home is writing to service users to tell them the outcome of their assessment and whether the home can meet or not meet their assessed needs. Case documentation confirms that progress is reviewed typically 4/6 week after admission. Service users confirm that they are supported to access a range of appropriate medical services, including specialist services. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Care planning has improved but is still not good enough because it is not always possible to see the link with the assessment documentation, the care plan and any relevant risk assessment. Service users report good access to the health care such as the district nurse or their GP. Staff ensure privacy when delivering personal care and they talk sensitively about dealing with death and dying. EVIDENCE: Each person has a written care plan that outlines the care and attention needed. Some plans show a tendency to concentrate on aspects of personal care, while others are better at including the wishes of each service user. For example one plan stated the service user would like to visit the shop with staff and would like to visit the hairdresser fortnightly, along with needing some assistance with bathing. Another emphasized the need to provide prompts to use the toilet but the plan did not clarify what staff needed to do to, “help the person to feel confident.” Examination of certain case files show that not all plans are being reviewed each month – something admitted by some of the staff. Case documentation shows that staff will encourage service users to see their doctor if needed. For example one case file reported a person as “feeling low” and this person was offered a doctors appointment. Another case file Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 11 reported that a person was “feeling bloated” and this person was also offered a doctors appointment. Another person who was experiencing occasional falls was made an appointment with their G.P. Also when care staff were concerned about the side effects of some medication these were reported to the G.P. There is evidence that people who need access to services such as continence advisors, dieticians, opticians and dentists are supported to obtain them. The home appears to enjoy good working relationships with the local district nursing service. Some service users report good satisfaction levels with the care they receive. For example one person said, “the staff are caring and the personal care they receive is good.” They also said that the, “staff encourage them to be independent.” Another service user said that; “the staff are caring and my privacy is respected.” Someone else said, “ I have no problems here.” While another said “all was well” [at the home]. But some service users did not give a full endorsement of the care they receive. One said they were kept waiting a long time when they rang the call bell for help” though someone else stated that their, “call bell is answered promptly.” It was observed that people who ring the doorbell are kept waiting. Another person said there is one staff member that they, “do not like and is not very caring”. It can be seen that staff are not always able to deliver prescribed care or the routine care a person needs. A service user also commented about the number of staff involved in meeting their personal care needs and this being a problem: though this was qualified by saying that the staff are caring. Staff report practical difficulties in, getting people up, getting them dressed and getting them washed or bathed due to insufficient staff available to undertake these tasks in the morning. [See under staffing] The arrangements for medication appeared in good order, except in respect of one resident where there was no photograph for new staff or agency staff to use to confirm the identity of the person prescribed medication. Records show that 2 staff administer medication so as to reduce the chance of mistakes. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and15 Satisfaction levels about what activities are provided in the home vary but staff try hard to do as much as they can. There is some evidence that shows that the service users opt out of some planned activities. Friends and family are made welcome. Menus and meals could be further improved. EVIDENCE: Service users confirm that they have 4 meals a day. Some service users report that they have made good friends at the home and that the home is a friendly place to live. Relatives confirm that they are made welcome and that if they wish they could stay for meals (this incurs a small charge). Visiting clergy take a regular Christian service usually one a month. Staff have arranged a number of summer activities including a successful garden party and BBQ. Service users were invited to make suggestions for spending the money raised. Some of the suggestions have already been actioned. The home has established good community links with a local business. Service users confirm that they are encouraged to personalise their rooms and many do. Two people who were receiving respite care reported that there is enough for them to do. The services own quality assurance questionnaire indicates that several service users would like more activities. Care staff also report that they do not have time to sit with service users and do activities. Currently the Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 13 accommodation is better at meeting the activity needs of people who are not residents and this imbalance needs to be addressed. During the inspection there was not much evidence to show that permanent residents were being encouraged to be active. It was observed that a lot of residents were asleep in their chairs. It was also noticed that there were also 5 staff in the staff room smoking for a period of approximately 20 minutes during which time service users in a nearby lounge were unattended, save for one person passing by. There were two other times when staff were observed to congregate in small groups i.e., 5 people were present in an area where some one was trying to give out medication/drugs and several staff were in the care office working on different things for a period of more than 15 minutes. Comments about food were generally favourable, though there was a gender difference, with men praising the food arrangements more than the women. One female service user said the food was “alright” while another said that they had, “enjoyed their lunch”. But another said the bread rolls were a bit doughy. The absence of roast chicken on the menu was also commented on. One of the male service users said that; “the food is good and there is plenty of it. ” Another also praised the food saying it was to his liking. Care staff were less reassuring about the quality of the food. One said their key resident had complained about the cabbage being hard. There were also concerns voiced about the mixing of green beans with swede. Other staff commented that the menus are “too reliant on mixed frozen/tin vegetables which old people don’t like and things on toast”. Another staff member said that giving service users, “crusty rolls with their soup is not to their liking and they all get left.” Care staff confirmed that extra portions are given out routinely if someone wants more and people can take meals in their own rooms. Service users confirmed this was so. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The 3 standards above were not fully inspected and will be inspected at the next inspection. The statement of purpose and the service user guide summarises how to complain and who to complain to. There is supporting documentation that shows that relatives are informed about the complaints procedure when they visit the home and that this information is also provided on the pre-placement visit EVIDENCE: Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 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 standard(s) The above NMS were not inspected on this occasion. However it is noted that the Council plan to refurbish this home in the near future. This will include providing improved fire protection, a new call bell system and some partial redecoration. Some toilet and bathroom areas have already been updated. EVIDENCE: Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 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 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) 27, 29 and 30 The staff team shows signs of being dysfunctional and this is having a negative impact on the way the home meets the needs of the service users. The service is achieving very good results at getting people to undertake and complete National Vocational Qualification training. EVIDENCE: Records show that the use of agency staff has diminished in recent months. Despite this improvement Agency staff covered 239 shifts during the period June to August 05. Additionally one person who has special needs benefits from having an allocated agency staff member for 8 hours each day. Staff report the staffing situation is more stable now. There is documentation in the home from the relevant employment agency to confirm that the staff they send to the home have undertaken a Criminal Record Bureau (CRB) checks. However it is not clear what level of check was made and the serial number of any such application. The file of one person employed by Swindon Borough was missing a copy of their Criminal Record Bureau check. In all other respects the recruitment of staff appears to be satisfactory with proper checks and paperwork in place. It appears that housekeepers do not make beds so care staff do this. In doing so this impedes on the amount of time care staff have to deliver personal care to those in need. Staff told the inspector that the current staffing arrangements means that service users routinely only get one bath/shower a week and rarely in the mornings – though staff will respond if someone requests an extra bath. Comments were also made by staff about not being Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 17 able to give key clients the time they need or having to delay someone getting up. Managers report difficulties in getting staff to modernise. More than 1 staff member said they did not want to work at the home much longer, one citing poor team working as a contributory factor. Managers and supervising staff report pockets of difficulty in managing certain staff and have concerns about different levels of professionalism. There were comments that some staff did not always do what was expected and that some staff in the past have given managers a ‘bashing’. Care staff report that during the time the drug round is carried out there are not enough staff on each unit to care for the service users. Some service users say you have to wait for attention at busy times. Some staff say they cannot always respond to the buzzers when it sounds if they are providing personal care. More than one staff member said they can find themselves in a dilemma in the mornings if they are attending to someones personal care and the call bell sounds. They worry it may not be safe or dignified to leave someone receiving personal care and it may not be safe not to respond to the call bell quickly. There was a comment in a care workers supervision notes that when assisting people with a bath this time could [also] be used as times to do reviews, assessments and care plans. The number of waking staff is considered satisfactory. Rotas show that no one under the age of 18 years provides personal care and all supervising staff are aged 21 years or over. Records show that 12 care staff have successfully obtained a relevant National Vocational Qualification level 2 and 8 care staff have successfully completed National Vocational Qualification level 3. They also show that 10 additional staff are in the process of completing their level 2 award. Housekeeping staff have also been successful at completing a relevant National Vocational Qualification. Some recently appointed staff report not having had an adequate induction. Some training records show some lapses in undertaking various statutory courses including refresher courses but on the whole most staff have undertaken these including awareness training in understanding abuse. In recent months several staff have undertaken a distance learning course in infection control, thus demonstrating an increased commitment to improving this aspect of care. However awareness raising/training on conditions associated with old age such as diabetes, arthritis asthma and hearing loss are minimal and not current. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 18 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) 31, 32, 33, 36 and 38 The new manager is beginning to make improvements to the home and to ensure more user satisfaction but progress is rather slow. Quality assurance is improving. The care arrangements for people receiving short-term care are a bit muddled. EVIDENCE: The current manager is deemed by the Commission to be a fit person to manage this service. They have successfully completed the Registered Managers Award and are currently undertaking their National Vocational Qualification level 4 to add to her level 3 award. It is evident the manager likes older people and appears compassionate. The manager’s desire to improve the standards of care is sometimes resisted or held back by a staff team that appears to have divisions and does not work well as a team. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 19 In recent months good attempts have been made to find out what service users think and feel about the service they receive. A recent survey showed that 8 out of 10 service users said they knew how to complain, 9 out of 10 said they were able to request a GP when needed. All stated that they had enough privacy but two people qualified this by saying sharing toilets was not to their liking. A feature of this inspection was the absence of service users identifying care staff by their name. A high proportion i.e. 60 said they did not know the names of their key worker. It is not clear why they say this but the possibility exists that there are too many staff entering their life for them to remember. No service user made any negative comment in the quality assurance survey about the care staff. At the time of the inspection the findings of the survey had not been actioned planned. The manager has plans to further develop the quality assurance process and was able to produce a detailed management plan of action for the year 2005/2006. It covers health and safety matters, team working, care planning, care practice and staff issues. Staff supervision is still underdeveloped, not very effective and in need of an urgent kick-start to get it going. Records show one to one meetings with a supervisor are very irregular. For example one staff member had only one supervision meeting in 11 months and several staff have not had more than 6 meetings in 12 months. Supervisory staff said they did not always have enough time to undertake these meetings and the manager admitted not enough supervision was being provided. It was also stated that the external assessor for National Vocational training had raised concerns regarding the lack of staff supervision. While staff impress as wanting to protect service users from harm and to care for them, not all aspects of safety were being well managed. When the fire alarm was sounded and staff congregated in the assembly area 2 staff were observed to discuss that, “it was stupid to have a fire practice at such a busy time”- thus undermining the attempts of the fire warden to manage the evacuation process. At the commencement of the inspection various combustible items were being stored in a skip, creating a potential fire hazard and other refuse was placed in the front garden area in an untidy manner. This was removed by the end of the inspection. The risk assessment in respect of fire safety was examined. The detail of which showed some factual errors i.e. it stated, “ all staff are given refresher training weekly in-house” and “fire drill and “evacuations are carried out weekly.” Records also show that weekly tests of the fire alarm were not every week i.e. there were 21 such tests covering a 26 week period and that monthly checks on the emergency lights were not carried out in the months of January, April, and June 05. Fire drills are however routinely practiced each quarter and the detection system is regularly serviced. People who receive short-term care are being placed in any vacant room. Staff cited examples where individuals on respite care get disorientated or momentarily ‘lost’ and on occasions wander into other peoples rooms. They also cited the difficulty of getting to know people on short term care if they are accommodated in different living areas. Two service users said this [policy] created difficulties for them. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 20 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 3 3 1 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 1 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 1 1 x x 1 x 2 Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 21 YES 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 OP3 Regulation 14(1) Requirement The registered person must ensure that the care needs of newly admitted residents are properly assessed. The registered person must ensure that each person who is admitted for respite care is provided with written standard terms and conditions of residency. The registered person must write to all people who have been assessed as suitable for the home to inform them based on the assement of their needs which needs the home can meet and which needs the home cannot meet. This must be undertaken retrospectively for any resident admitted since April 1st 2005 and for any new resident. Further consideration must be given as to the best way to ensure all relevant staff have undertake awareness raising/ training in conditions associated with ageing There shall be a photograph of all residents who are administered medication by staff Timescale for action 16/10/05 2. OP2 5(1)(b) 16/10/05 3. OP3 14(1)(d) 16/10/05 4. OP4 OP30 OP31 12(1) 18(1)(a) 16/11/05 5. OP9 13(2) 16/10/05 Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 22 employed in the home that is properly named and is readily available to the staff who administer medication. 6. 7. OP15 12(3) 16(2)(i) The staff who plan menus must be provided with guidance on what older people like to eat and what difficulties older people may have in eating and drinking. They must also take into account how residents would like their food presented and any stated food preferences. Before an agency worker is deployed at the home the manager or person acting on their behalf must be informed in writing by the Agency when the Agency last undertook a Criminal Record Bureau check, and/or a POVA check and informed as to the status of the check in relation to the agency worker. A competent person should review the current fire safety risk assessment to ensure it is based on accurate data. The registered manager must ensure that the fire alarm call bell system is tested every week. The registered manager must ensure that the emergency light system is checked each calendar month. All care staff must meet with their line manager, or other competent person, at least 6 times a year in private. The purpose of such meetings is to discuss work achievements and problems including the homes stated purpose and operational standards and the care needs of the service users. A record of each meeting should be kept in writing, including any action 16/11/05 8. OP29 19(2) 16/10/05 9. OP38 23(4)(a) 16/11/05 10. 11. OP38 OP38 23(4)(c) 23(4)(c) 16/10/05 16/10/05 12. OP36 18(2) 16/11/05 Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 23 13. OP 38 23(4) 14. OP33 35 24(1)(2) plan. Note; This requirement is carried over from the previous inspection and should have been met by 01/04/05. The timescale has been extended to 16/11/05 The person in control must inform the Commission in writing which recommendations contained in the fire officers letter dated 16 March 2004 are outstanding and, if any, the reasons why. Note; This requirement is carried over from the previous inspection and should have been met by 01/03/05. The timescale has been extended to 16/11/05. Those with managerial responsibilities for managing the home must ensure the home undertakes a review of the quality of the care provided in the home covering a period of not less than 3 months. Such a review should obtain where it is practicable to do so a reasonable sample of the views of users of the service and those who represent them including their friends, relatives any advocates, care managers, health care workers and the staff working in the home who may be able to form a reasonable opinion of the care provided. The review must be completed by 01/08/05, and must detail its main findings in writing. Note; This requirement is carried over from the previous inspection and should have been met by 01/08/05. The timescale has been extended to 01/12/05 16/11/05 01/12/05 Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP3 Good Practice Recommendations It is strongly recommended that home uses as a template of the headings listed NMS 3:3 when asesssing each person needs. It is strongly recommended that the home introduces a system as soon as practicable that is designed to improve the way key admission information is captured and recorded and to ensure it is accurate and kept date. It is recommended that that all relevant staff are instructed to date intial or sign all case documentation they write and that supervisors check from time to time that they are doing so. Further consideration should be given to the concerns raised in this report about small groups of staff congregrating around the persons administering medication and at other times. It is recommended that all residents have their care plan reviewed each calendar month. Active measures should be taken to reduce, where it is practicable to do so, the number of different staff who provide individuals with personal care. It is recommended that further consideration be given to how best to increase the range of activities available to residents including increasing the opportunities for more events and activities that are arranged spontaneously. The responsible individual should urgently review which staff should be expected to make beds, ensuring that the arrangements do not hinder service users receiving the personal care they may need. It is strongly recommended that the registered persons urgently undertake a review of what additional measures, if any, are needed to ensure that all staff working at the home maintain good personal and professional relationships with each other. The practice of using bath times to review care plans, assessments (other than assessments associated with safe bathing) and reviews should cease. In view of the number of service users who were not able to recall the names of key staff further consideration should be given as to staff wearing name badges. DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 25 3. OP3 OP7 OP4 4. 5. 6. 7. OP7 OP7 OP12 8. OP27 9. OP27 10. 11. OP27 OP33 Fessey House 12. 13. OP30 OP33 14. OP15 The results of any of quality assurance survey should be collated and the results made to service users and those who respresent them and to the staff. It is recommended that a named senior manager periodically audits how well the service progesses any requirements and/or recommendations arising from CSCI inspection reports. Measures should be taken to monitor service user satisfaction levels with the food arrangements. Note; this recommendation was made at the previous inspection. The manager was not able to confirm it had been met so it is repeated. Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 26 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 Fessey House DD51_D01_S35422FESSEYHOUSE_V232261_070905_STAGE4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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