Inspection on 10/10/05 for The Fairway

This inspection was carried out on 10th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Fairway 20/04/07

The Fairway 02/05/06

The Fairway 27/01/06

The Fairway 31/01/05

The Fairway 15/07/04

The Fairway 04/03/04

The Fairway 19/08/02

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Fairway Green Lane Highlands Oxhey Hertfordshire WD19 4LX Lead Inspector Julia Bradshaw Unannounced 10/10/05 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. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Fairway Address Green Lane Highlands Oxhey Hertfordshire WD19 4LX 01923 221 345 01923 209 997 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) Quantum Care Limited James Antwi Care Home 45 Category(ies) of DE(E) DE(E) Dementia - over 65 - 45 registration, with number of places OP OP Old Age - 45 PD(E) PD(E) Physical Disability - over 65 -45 The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are none. Date of last inspection 31.01.05 Brief Description of the Service: The Fairway was formerly a purpose built County Council care home that was refurbished by Quantum care in 1992 .It provides accommodation on three floors and in four separate units. All units are provided with a small kitchen in which residents and relatives may make drinks and snacks. The home is located in Oxhey, close to Watford town centre and local shops are within walking distance of the home. There are good public transport links with a local train and bus services nearby. The home is set within pleasant grounds and is located off a main road within a side road. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the year and took place early morning to late afternoon. The majority of time was spent talking to service users actively seeking their individual views and feedback concerning the running of the home, meals, activities, choices, care plans, decoration and any other environmental issues. Time was spent engaging in activities with the service users and time was spent observing lunch and seeking views of a small group of service users. What the service does well: Supervision and appraisals are offered and feedback from staff spoken to confirm that the process was effective a useful tool. Records were well maintained for all staff. The home offers a comprehensive and extremely well structured induction programme for all new employee’s. This ensures that core skills and a value base practices are established prior to working with the service users. The environment is maintained to a high standard with both internal and external decoration being well maintained and presenting a homely feel. All service users rooms are decorated to personal taste and all are encouraged to personalise their rooms. During the inspection the views of a visitor were sought, many positive comments were made in respect of the home in general. A visitor summed up the home as being “a caring and comfortable home in which to live”.” The home provides a range of activities and a specific activity coordinator is employed to work with service users, including the dementia unit. Feedback from service users confirmed the range of activities available and positive comments were received. The home has small kitchenettes in each of the four units. Main meals are prepared within the main kitchen and snacks and hot drinks are prepared within individual unit. The main kitchen is very clean and well maintained. Records observed were detailed and well organised. The menu is a four-week rolling menu, all service users have a variety of choices available to them and are actively empowered and encouraged to make choices. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 6 The home has a detailed and effective quality assurance system in place, actively seeking the views of the service users, relatives and other visiting professionals. Internal audits occur regularly with specific auditors in the home covering a range of measurable indicators. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.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 The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.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) 1,2,3,5. All service users are provided with accurate and adequate information, visits and discussions prior to admission to the home, ensuring that they are empowered and encouraged to make informed choices about where to live. EVIDENCE: The home has a detailed and comprehensive Statement of Purpose in place, providing sufficient information for all prospective service users, friends and relative and supporters. All service users are provided with the documents prior to admission to the home and following review. The service user or representative and Registered Manager sign the document on admission to the home. Care records of service users were inspected and there was evidence of pre admission assessment of needs being carried out in each case. The home receives a copy of the pre admission assessment of needs of prospective service users for those who are funded by the Social Services and discharge letters from hospital, where applicable. The manager or a senior member of staff would carry out the home’s own pre admission assessment of needs of any referred service user. Staff members were observed to be interacting well with service users; demonstrating good skills and knowledge to meet the specific care needs of the respective clients’ group. Prospective service users The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 9 are invited to look around the home. Relatives invariably visit the home prior to admission of their next of kin to the home. The initial admission would be on a trial period for a mutually agreed length of time, which can be extended if need be. This allows the home staff ample opportunity to further assess the service user’s needs and to formulate a detailed care plan. The manager and staff should be congratulated on achieving accreditation from Hertfordshire County Council for one of their units that provides Dementia Care. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.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) 7,8,10. Service users care plans set out in detail the provision of care required on an individual basis. Service users have full assessments completed on their individual files, ensuring that an individual plan of care can be set out meeting individual needs. The home has a comprehensive medication policy and procedure guidelines, which supports in the safe administration of medicines. EVIDENCE: All service users care plans were generated from the pre admission assessment and provides the basis of care to be offered to the individual. All care plans detail specific actions to be taken by the staff to ensure all aspects of the service users health, personal and social care needs are met. All Care plans will be reviewed once a month to ensure monitoring and changing needs can be addressed. The plan is drawn up with the involvement of the service user as much as possible, some care plans had been signed by the service user and or representative. Care plans were tracked as part of the inspection The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 11 process. All service users spoken with appeared well cared for. Self-care is promoted within the home where ever possible. The ethos of good practice within the home ensures that preventive and restorative care is provided. Specialist medical support and advice is offered within the home to any service users who may require it. All necessary equipment is provided to meet service users needs. Following discussions with service users is was confirmed that the staff are very caring and supportive, encouraging them to make decisions about their lives with appropriate assistance provided. Service users commented that they felt respected at all times. Privacy and dignity was observed being upheld within the home. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.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) 12,13,14,15. The home supports all service users to maintain family, representative and community links as they wish, thus empowering and encouraging service users to maintain, respect, dignity and personal autonomy over choices in their lives. Wholesome, adequate, varied meals are provided within the home presenting a well-balanced nutritious diet for all service users supporting them to maintain a healthy life. EVIDENCE: The home employs an activities coordinator who is providing a range of meaningful activities. Systems are implemented within the home, to record accurately the activity preferences of each service user and to monitor the activities partaken. The manager has included this worker in the dementia training provided by Quantum Care. Feedback from service users was positive regarding the activities available. The home encourages visitors and volunteers and holds events during the summer months and during the Christmas to raise monies for the amenity fund. On the day of the Inspection a group of people were going to St Albans for a shopping trip. However the home should actively persue the option of recruiting staff/volunteers who are able to drive the minibus as currently the manager is the only designated driver which could have a negative effect on the service and the availability of the manager at the home. A calendar of The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 13 events was on display. Involvement in other local community events is encouraged; emphasis is give to autonomy and choice for the service users. Service users views and opinions are expressed freely within the home and efforts are clearly made to ensure that service users maintain vital links, personal autonomy and choices. If further support and or advice is required in order to ensure freedom of choice for the service users staff are able to link with specialist advocacy services in the best interest of the service user. Wholesome meals are provided. Feedback provided by many service users was positive regarding the choice and availability of foods. A four-week rolling menu is in place. All service users can make, and are empowered and encouraged to make, choices over the meals and the foods they eat. Hot and cold drinks are available throughout the home. Lunch was observed and appeared to be unhurried and a calm atmosphere. The kitchen was well organised with recording systems in place. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.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) 16,18. The home has a comprehensive complaints procedure in place, which ensures that the rights of all service users are maintained. Robust polices, procedures and training for staff is in place regarding abuse, to ensure all service users are protected. EVIDENCE: The home holds a comprehensive complaints procedure, which is on display throughout the home. The ethos of good practice within the home ensures that all complaints are taken seriously ad acted upon. The management of the home encourages and empowers staff and service users to make complaints with effective resolution. The Complaints procedure includes clear time scales and is accessible to all. A record of all complaints is maintained. Service users and visitors spoken with stated that they were aware of the complaints procedure and would not hesitate in making their complaints known to the management of the home. They stated that they felt confident that their complaint would be dealt with effectively. The home has its own Whistle Blowing procedure, which is displayed in various locations in the home and has adopted the Hertfordshire Adult Protection Procedure. Staff members spoken had a clear understanding of the policy following further briefing in staff and team meetings. The home has a good system of safekeeping service users’ money. Although the “pooling” of personal monies in not regarded as good practice, there are clear accounting practice in place to ensure any discrepancies are identified and rectified The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 15 immediately and effectively. Service users have been provided with lockable storage facilities where appropriate. Where service users have not requested lockable storage facilities or where they are not able to operate lockable facilities due to their mental state, this should be indicated in the care records. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22. The home is well maintained, equipped and furnished. All areas are safe, comfortable and homely. This ensures that service users are able to maximise their independence and live in a warm, suitable, caring environment. EVIDENCE: The home is well maintained, clan and tidy. The home shares a handyperson within the Quantum Care organisation. This has ensured that the home has remained in good order throughout. There is a planned renewal and redecoration plan in place, with all emergency minor works being completed promptly. The home is bright and airy, promoting an accessible safe space for all service users. Service users spoken to confirmed that they like the decoration of the home and feel that it is a homely calm environment to be in. Indoor and outdoor communal space is well decorated in relaxing and cheerful colours. The grounds are accessible to all service users, although there are some steep areas that some service users would need supervision .Communal indoor space provides lighting of a domestic style and a friendly homely The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 17 atmosphere suitable for the needs of the service users. Bathrooms and toilet facilities are in abundance throughout the home, ensuring that they all suitably located for all service use, staff and visitors. Service users spoken to stated that there are ample toilet facilities available at all times. Specialist equipment is also provided in abundance throughout the home, ensuring all identified needs can be met. Suitable grab rails and other aids are available throughout the home. A call point system is available and call bells are suitably located for all service users. The system allows there to be a call record maintained to ensure a reasonable response time is provided to all service users. Service users confirmed that a reasonable waiting time occurs if they require assistants. The home has a passenger lift to enable service users to have access to the 1st floor and lower ground floor. All rooms are single and provide adequate and suitable en-suite facilities. Rooms are personalised and well decorated. All service users are encouraged to personalise their rooms to individual tastes. Laundry facilities are sited so that solid articles are not carried through areas where food is prepared. Hand washing facilities are provided throughout the building and staff are actively encouraged to maintain good hygiene practices. Policies and procedures are in place for the control of infection. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 18 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) 27,28,29,30. The home is suitably staffed to ensure that individual service users needs are met at all times. Staff are adequately trained ensuring service users are in safe hands at al times. Recruitment and selection polices and procedures are robust ensuring service users are protected. EVIDENCE: Staff were seen to be working in such numbers to meet all service users needs. On the day of the Inspection there were 7 care staff on duty plus two managers, one administration worker, one cook and one kitchen assistant. Staffing rotas were checked and reflected that adequately trained staff are working at any time in the building. Service users confirmed that they feel their individual needs are met with staff that are adequately trained. The manager has implemented some staff changes since the last inspection took place in which existing staff have been transferred into new units in order to utilize their training in dementia. Some staff have found this transition difficult and it is hoped that this arrangement will be reviewed within the next three months to ensure that this arrangement is best serving the needs of the service users. The home provides an excellent training programme. Recent training includes, Fire safety, Adult protection, first aid, dementia training. The home currently has a total of 6 individuals that have competed their NVQ level 2. Two staff have NVQ level 3 and three staff are currently studying for their NVQ assessors award. The home has worked hard to encourage and support staff to embark on NVQ training but unfortunately several staff who recently qualified have all The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 19 since left. There are sound recruitment and selection procedures in place, ensuring suitable checks have occurred on all staff for the safety and protection of the service users. The home has a detailed induction process for all staff that is staggered for the staff member ensuring that key task and training can occur at key stages throughout the process. The training and induction programme is in line with the National Training Organisations guidelines and ensures that staff are meeting the aims of the home and meets the changing needs of the service users. All training needs are identified in supervision and appraisals. The home has an annual training schedule of which all staff are empowered and encouraged to apply. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 20 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, The manager’s qualifications and style of operation of the home ensures that it is run in the best interests of the service users. Health and safety issues are well maintained and managed ensuring that the welfare of staff and service users is protected. However individual risk assessments have not been fully completed. EVIDENCE: Feedback from service users determined that the management and the ethos of the home is positive. The manager of the home displayed clear direction and leadership which both the staff and the service users were able to understand. The home conducts an annual questionnaire, which is sent out to families and carers in October and the results analysed and published. Service user meetings are held every six weeks, however there was insufficient evidence The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 21 that these meetings have been held recently and therefore the manager needs to ensure these meetings are held regularly and minutes are taken and agreed by all parties. Staff spoken to confirmed that they have supervision not less than a minimum of six times per year. There is a need for the home to ensure that all staff receive a minimum of six formal one to one supervision sessions per year and records taken. The designated representative who carries out the regulation 26 visits must ensure that the reports from these visits are sent to the home .The last report seen on the day of the inspection was April 2005. All records required by regulation were available upon request and were held in accordance with the Data Protection Act 1998. The home holds both generic and individual risk assessments and these had been reviewed since the last inspection. However there was no evidence on service users files to ensure that people who are at risk of choking have been fully assessed. Fire records were checked and the most recent fire drill was carried out on 24/9/05. Weekly fire checks are being carries put and recorded effectively. The last annual service was carried out on the 15/6/05.The last COSHH assessment was carried out on the 6/5/05. The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 22 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 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x x x x The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 (4) (c) Requirement The manager must ensure that risk assessments are completed on all service users who are at risk of choking. Service user meetings must be held more regulalrly. Regulation 26 meetings must be carried out on a monthly basis and reports held within the home. The manager must review the curent pratice of putting Kylie sheets on lounge furniture in order to ensure the dignity and respect for service users is maintained. Timescale for action 11/10/05 2. 3. OP14 OP33 12 (3) 26 (4) (c) 11/10/05 31/10/05 4. OP10 12 (4) (a) 20/10/05 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 Good Practice Recommendations The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 The Fairway 20051010 I52_s19568 The Fairway v233692 Stage 4.doc Version 1.30 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. 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