Inspection on 04/06/07 for Fieldway

This inspection was carried out on 4th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fieldway 26/10/06

Fieldway 16/02/06

Fieldway 22/09/05

Fieldway 02/11/04

Fieldway 12/05/04

Fieldway 10/12/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Fieldway 40 Tramway Path Mitcham Surrey CR4 4SJ Lead Inspector Emma Dove Unannounced Inspection 4th June 2007 11:30 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 Fieldway DS0000019090.V343550.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. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fieldway Address 40 Tramway Path Mitcham Surrey CR4 4SJ 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 8648 3435 020 8685 0287 mackenis@bupa.com BUPA Care Homes (AKW) Ltd Mrs Isabella Mackenzie Care Home 68 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (68), of places Physical disability over 65 years of age (37) Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: Fieldway Nursing and Residential Centre is a registered care home for sixtyeight older people including thirty-seven service users who may also have physical disabilities and thirty-one who may have dementia. Sixty-five people currently live there. Fieldway Nursing and Residential Centre was purpose built. Accommodation is provided over two floors. Nursing care is on the ground floor, with residential care on the first floor. The two units have two lounges, a dining room, two assisted bathrooms, and have thirty-seven and thirty-one single bedrooms each with ensuite toilet and wash hand basin. Both floors are served by a lift. Residents have access to gardens to the side and rear of the building. Parking is available at the front of the home. Information about the CSCI is available to residents and visitors. The current fees range from £630 to £800 per week. Fieldway DS0000019090.V343550.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 five and a half hours on the 4th June 2007. Two inspectors visited, spoke with residents, relatives, staff, the deputy and manager. Records were looked at and the communal areas and eight bedrooms were seen. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose should include the date it was written. Further work is required to improve information available to staff, focussing on person centred plans, to ensure residents needs are fully met. The provision of palliative care services could be improved by staff completing training and taking advice from specialist nurses and evidencing their training in their recording. Review the complaints process with residents and their relatives. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 6 Continue with redecoration schedule so that all the environment is maintained at a good standard for people. The continued storage of items in bathrooms must be addressed. Staff must receive training in dementia care to ensure needs of people on the first floor are fully met. The staff recruitment process must be reviewed with checks completed as required and records contain the necessary information. 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. Fieldway DS0000019090.V343550.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 Fieldway DS0000019090.V343550.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose sets outs the aims and objectives of the home and includes a Service Users Guide. These documents provide basic information about the services and specialist care the home offers. The Guide is available to individuals in a standard format. Assessments are completed prior to admission, although they need to contain full details of individuals needs. EVIDENCE: The Statement of Purpose contains information about the organisation and the services provided, to help people decide whether to move in. This document should include the date it was written and where specialist services are offered, must reflect current best practice. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 9 Information is provided in English and consideration must be given to it being provided in languages and formats accessible to all residents. Placing social workers and senior staff complete assessments before a person is admitted. The assessments seen did not contain full details of peoples life history and cultural background. This lack of information means staff do not always know residents needs and are not able to ensure needs are met. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place with further work required to ensure all needs are recorded, particularly around residents social history, culture and sexuality. Peoples health needs are generally well recorded with appropriate action taken to meet them. Medication is generally well managed and recorded. EVIDENCE: A new care planning system has been put in place since the last inspection. The format does not include much space for staff to include detailed information. We found some care plans had been developed from assessments. Care plans seen had not been completed in full and the guidance notes for staff were not followed. The ‘map of life’ and ‘life biography’ sections of care plans must be completed in full so that staff have access to information to meet residents needs. One case file identified that the person had communication problems Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 11 due to dementia, with no further information about how they may communicate in their first language, rather than English. Risk assessments are in place and updated when necessary. Peoples health needs are generally well recorded with two exceptions. Mouth care was not recorded in one assessment and care plan. One daily record noted an eleven day gap between treatments, which was not the assessed timescale. Appropriate medication policies, procedures and practices are in place to meet residents health needs. Records seen were up to date and signed by staff. Staff administer medication from a monitored dosage system. Some ‘as required’ medication is recorded as ‘give one or two tablets when necessary’. It is not clear in some cases when one or two tablets are given. One person’s medication record sheet did not include an allergy that was noted on their medication profile. Another person’s allergy information was updated at the time of the visit. Staff were seen to treat residents with care and respect. Residents made positive comments about the staff and care they receive including: ‘I am treated well’ and ‘it’s a friendly place’. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of group activities are available as well as one to one time with activities staff to meet peoples social and leisure needs. People who use the service have the opportunity to maintain important family relationships. Visitors are welcome and residents can see visitors in communal areas or in private in their bedrooms. EVIDENCE: Two staff are employed to organise activities for people and outings in the local community. The manager said that they have borrowed transport from another home and had been on trips in the local community. People were seen to be talking with staff, reading the paper, sitting in their bedroom, listening to the radio, joining in with activities, listening to music and spending time with visitors. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 13 As previously noted, case files do not contain sufficient information about peoples social, cultural and religious wishes to enable staff to meet these needs. Visitors were seen to be welcome and supported by staff. One visitor said that they are helped to keep in contact with their relative and kept up to date with any changes in need. Peoples comments about the food included: ‘lunch was nice’, ‘they give me something different if I don’t like the meal’ and ‘the food is alright’. Meals are served in dining rooms and some people were seen to remain in their bedrooms for lunch and evening meal. Staff take meals to people on a tray. Afternoon tea and cake was seen to be enjoyed by residents, and the celebration of Birthdays is supported by kitchen staff who provide a cake. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 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. 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 service has an appropriate complaints procedure, which is available to residents and their representatives. Suitable protection of vulnerable adults policies are in place. EVIDENCE: The complaints policy is available and people were aware of how to make a complaint, no issues were raised at the visit. The manager reported that no complaints had been received since the last inspection in October 2006. The manager’s completed self-assessment indicated that one complaint had been received in the last year. Staff have completed training in the protection of vulnerable adults, although it was not clear how many staff and when this training was completed. Fieldway DS0000019090.V343550.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Fieldway was purpose built as a care home. A few areas of the home continue to show signs of wear and tear, the redecoration programme has commenced with a number of communal areas redecorated and new carpets fitted. The cleaning programme has been reviewed and all areas of the home were seen to be clean and generally free from odour. EVIDENCE: Fieldway provides a homely atmosphere. It is currently being redecorated and maintained to reach a satisfactory standard. An on-going redecoration schedule is in place, which has included the redecoration of the entrance, lounges, serverys and some bedrooms with some new carpet fitted in lounges and the entrance. Further work is required to ensure all areas of the home are at a good standard. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 16 All bedrooms are single have an ensuite toilet and wash hand basin and those seen have been personalised to residents choice. On the ground floor peoples bedrooms have their name and a photograph of their named nurse and key worker. Residents were seen to be comfortable in their bedrooms and made comments including: ‘I’ve got my belongings with me’ and ‘I like my room’. Two lounges, a dining room, two assisted bathrooms and a number of toilets near communal areas. Two bathrooms are still being used to store equipment. The garden was seen to need attention so that residents can access and use the facilities. The home was seen to be clean with an improved cleaning schedule in place. A few odours were noted on one floor and the manager reported that this was being addressed with new carpeting. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were seen to be sufficient to meet peoples needs. Staff recruitment policies and practices need to improve to ensure gaps in employment are checked. Staff have access to training. EVIDENCE: Residents made positive comments about staff, saying: ‘they help me’ and ‘staff listen’. Staff were seen to be responsive to residents needs, to offer support and reassurance to people in their bedrooms and to listen to residents. Staffing levels were seen to be sufficient to meet the needs of current residents. Staff files seen contained the required checks with one exception. Gaps in employment had not been explored and references were from a relative who works at the home. Recruitment checks must include checking and recording gaps in employment and references should be sought from another source than the home. Staff reported that they have access to training. A staff training matrix has been developed which identifies training staff have completed in 2007. This matrix enables easy access to which staff have completed training and which Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 18 staff require refresher training and updates. Records indicated that all staff have completed training in health and safety and fire safety. One member of staff has completed training in infection control. Four members of staff are trained in the use of first aid. Six members of staff have completed NVQ to Level 2, although the managers assessment noted that twelve members of staff have completed NVQ to Level 2. There was no evidence available to confirm that nurses have completed any training other than medication. To meet the needs of specific groups of people at the home, nurses must complete training in palliative care and the care of pressure areas. Staff must complete training in the care of people with dementia, to ensure that they are able to meet peoples needs. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 19 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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has the knowledge and skills to run the home. The systems for meeting health and safety requirements are good. EVIDENCE: The manager has been at the home for three and a half years and knowledge and understanding of residents needs. A residents and relatives meeting was held on the 3rd June 2007 when people were given the opportunity to speak about the services provided, healthcare, activities and repairs to equipment. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 20 The manager reported that she has sent out questionnaires to residents, relatives and other stakeholders and is awaiting responses. The organisation completes an annual customer satisfaction survey. A copy of the survey for 2006 was sent to the CSCI, the action plan from this should be sent to the CSCI. A representative from the organisation visits every month and writes a report. Copies of this report are sent to the CSCI. Residents are able to deposit money with the home for safe keeping. The systems for managing residents finances are well documented and managed. Staff reported that they are supported in their work, however records indicated that formal supervision has not taken place every two months. Good systems are in place for health and safety monitoring with checks of the gas, electricity, fire alarms, hoists and lifts up to date. Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 21 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 4 Requirement The Statement of Purpose must include the date it was written and where specialist services are offered, evidence must be available to show that it includes current best practice. Care plans for each individual must include information of their social, emotional, cultural and spiritual needs and wishes, with information on how these needs will be met. (timescales of 15/12/05, 01/06/06 and 09/03/07 not met) The staff recruitment process must include checking gaps in employment. Staff must evidence in their practice and recording the training they complete in dementia and palliative care. All staff must receive regular supervision. Timescale for action 30/08/07 2. OP7 15 30/08/07 3. 4. OP29 19, Sch 4 18 (1) c 30/08/07 30/08/07 OP30 5. OP36 18 (2) 30/08/07 Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 23 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 OP7 Good Practice Recommendations Care staff should be provided with training on person centred planning and the documentation used within the home to ensure care plans are completed in full, in line with the guidance. Consideration should still be given to the provision of an appropriate vehicle, to enable residents to access community activities and facilities. The storage of equipment in bathrooms should be reviewed. 2. 3. OP12 OP19 Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Fieldway DS0000019090.V343550.R01.S.doc Version 5.2 Page 25 - 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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