Inspection on 07/07/05 for The Fairways Residential Care Home

This inspection was carried out on 7th July 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 Fairways Residential Care... 18/06/07

The Fairways Residential Care... 11/12/05

The Fairways Residential Care... 03/12/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE The Fairways Residential Care Home 269 Church Road Urmston Manchester M41 6EP Lead Inspector Joe Kenny Unannounced 7 July 2005 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 Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Fairways Residential Care Home Address 269 Church Road Urmston Manchester M41 6EP 0161 746 8160 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) The Knoll Care Partnership Ltd Responsible Individual Matthew James Callaghan Mrs Amanda Jayne Callaghan CRH Care home PC Care home only 20 Category(ies) of DE(E) - Dementia - over 65 registration, with number MD(E) - Mental idsorder - over 65 of places OP - Old age The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 20 service users to include: Up to 20 service users in the category of OP (Old age, not falling within any other category) Up to 20 service users in the category of DE(E) (Dementia - over 65 years of age). Up to 20 service users in the category of MD(E) (Mental Disorder, excluding learning disability or dementia - over 65 years of age). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 3 December 2004 Brief Description of the Service: The Fairways provides residential accommodation and personal care for up to twenty (20) service users within the category of old age (OP), but any of the service users could additionally have a mental disorder, (excluding learning disability) or dementia. On the day of inspection there were twenty (20) service users living at the Fairways. The Fairways is a large property which is set in pleasant grounds. To the rear of the property is the local golf course. The grounds are enclosed and offer residents ample external space to sit out, weather permitting. There are designated car parking spaces to the front of the building. The home is situated in a residential area of Flixton and is close to the local bus route. The main local shopping area is Urmston. The Fairways has a church and two pubs nearby. The home has 20 single bedrooms of which 11 are en-suite. There is passenger lift access to the first floor. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the Fairways was carried out unannounced and took place on the 7 July 2005. On the date of the inspection 20 residents were accommodated and the manager, deputy manager and three care assistants were on duty. The inspection involved a tour of the home, inspection of records/care plans and procedures such as administration of medication, discussions with staff, residents and the manager of the home. The home had taken appropriate steps to address requirements and recommendations made at the last inspection of the home. The registered manager, deputy and three carers were on duty to support the 20 residents accommodated at the time of the inspection. Whilst touring the premises the opportunity was taken to spend some time in discussion with residents about life in the home. Residents spoke positively of the support they received from staff. Residents confirmed that they could choose how they spent their day, choose what time they got up and when they went to bed. A number of residents choose to remain in their bedroom during the day. Residents confirmed that staff respected their wishes and would periodically call on them. The manager confirmed that visitors are welcome and there are no restrictions on visiting times to the home. The home continued to monitor and develop recorded information on care plans and risk assessments carried out on residents. The manager demonstrated a commitment to maintaining national minimum standards in the home. What the service does well: The home continues to provide a service which responds to the choices and needs of residents. Residents stated that staff were supportive and respected their wishes. Records relating to residents care and associated risk were being well maintained and regularly reviewed by staff. The manager stated that the home had established good links with relatives of residents at the home and that relatives continued to support residents to contact community resources. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 6 The home continued to establish and maintain a homely approach to care delivery and aspects of daily living. 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 Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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 Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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) 3 and 6 Procedures at the time of referral or admission ensure residents or their representatives are given the appropriate information to assist them in making a decision about moving to the home. EVIDENCE: The admission process is co-ordinated by the manager and senior staff working at the home. Residents or their relatives will be provided with information about the home, such as the Statement of Purpose. Residents are given the opportunity to visit the home for the day, to have a meal and meet other residents and staff. Residents confirmed that this did happen when they moved to the home or indicated they were supported by a family member at the time they moved there. The manager stated that links with family are established at the time of admission as family members are consulted with to assist the home in establishing an agreed plan of care. Some residents indicated that if they could they would clearly wish to remain in their own home setting and spoke about the difficult decisions they had to make. When speaking about the care and support provided by staff in the home, they said that staff were very supportive, helpful and caring. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 9 The manager stated that a positive link is maintained with family members who are welcome to visit the home at any time. The dependency levels of residents varied, five residents remained independent requiring minimum support. A number of residents choose to get up early and choose to rest early in the day also. A homely aspect of the service was the arrangement for breakfast in bedrooms. All residents receive a contract and statement of terms and conditions at the time of admission to the home. The home does not provide intermediate care as described in the standard above. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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 Procedures in place ensure the health care needs of residents are met. Service users health, personal and social care needs are detailed in their care plan and regularly reviewed by staff working in the home. Medication procedures ensure residents’ medication is administered as prescribed. EVIDENCE: Care plans are held securely in the main office. Staff continue to maintain daily reports on the support they offer residents. Records are made throughout each shift with up to three to four entries per day. The information was informative and staff also maintain recorded evidence of support provided by other professionals. Care plans were being regularly reviewed. Plans of care are set up as individual files under a series of sections and headings specific to each individual. Information on care and health needs was documented and evidence of support from other professionals was documented under the relevant heading. The home had taken action to ensure associated risk to individuals had been assessed and appropriate strategies of intervention put in place. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 11 Information on the files demonstrated that a review of care was conducted by staff on a monthly basis. No resident required care relating to pressure sores. The manager did confirm that some residents were on preventative pressure care through provision of pressure relieving mattresses. The Diabetic Nurse visits to monitor blood sugar levels of three residents. Staff were observed to be supportive and spoke to residents prior to and when supporting an individual on a care activity. There was an established staff team who were familiar with the needs of individual residents. Staff consulted residents regarding their preferences and choice. This was evident in relation to catering arrangements for the evening meal on the date of the inspection. Staff demonstrated that choices were available through the menu plans. The rights to privacy and dignity were addressed through residents care plans, detailing where support should be offered on personal care issues. Residents can also receive their visitors in the privacy of their room. The daily records were informative and well maintained by staff. Care plans were being regularly reviewed and evidence was available to confirm this. The manager described the process for administering medication in the home. The medication trolley and records were examined as part of the inspection. The trolley is held securely and the system was found to be in order. The Medication Administration Record was found to be completed, with no gaps in signatures. The procedures relating to medication also evidence a trail of medication into the home and medication returned for disposal. A designated group of staff (seven) were assigned with responsibility for administering medication and all had received appropriate training, provided by the supplying pharmacist. The pharmacist also provides backup advice on a three monthly basis. Sample signature of all staff with responsibility for administering medication must be kept at the front of the medication administration records. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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) 13. 14 and 15 The personal and social interests of residents are respected and responded to by the management and staff team working in the home. EVIDENCE: Residents stated that staff were supportive and respected their wishes in relation to daily choices and preferences. Residents confirmed that they choose what time to get up and what time they went to bed. Staff also stated that they hold discussions with residents to ensure their preferences are acted upon. The home operates an open policy on visiting times to the home and residents can receive their visitors in the lounge or in the privacy of their bedroom. Programmes of activity are held internally and some events will be held in conjunction with the participation of residents from the second home, run by the owners. This will primarily will be outings to agreed venues. Residents confirmed that social and leisure events are planned with activities such as crafts, pursuit of personal interests such as audio books and special events to celebrate birthdays. Staff working in the kitchen confirmed that the choices of residents are respected and an alternative is offered. It was recommended that a record is kept of choices offered. Meal arrangements are planned using a three week The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 13 menu plan. It was encouraging to hear that residents could have their breakfast in their bedrooms if they wished. There were ample provision in the home and evidence of fresh produce such as fruit and vegetables. The manager confirmed that staff working in the kitchen had received training in basic food hygiene. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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 and 18 The home’s complaints procedure is available to residents and relatives to raise concerns about the service. Procedures relating to protection of vulnerable adults protected residents from risk of abuse. EVIDENCE: The home has an established procedure and policy in relation to dealing with complaints. The information provided to residents and relatives in the policy statement details who to be contacted if you have a concern or complaint about the service provided at the home. The information also details the role of the Commission. The procedure is detailed in the service users guide. In the period since the last inspection the home received one complaint relating to food. The records relating to the incident indicated that the complaint had been resolved to the satisfaction of the complainant. No complaints about the home were received by the Commission in the same period. The home had a copy of the Protection of Vulnerable Adult Procedure developed by the Local Authority. The manager was advised to retain evidence that all staff had been given the opportunity to read the document and sign the tracking form to confirm they had read and understood the documents. The home is advised to evidence that training on the implementation of the procedure had been offered to staff where assessed as required. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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) 19, 22, 24 and 26 The home is well maintained comfortable and provides residents with a safe environment in which to live. EVIDENCE: The home is well maintained internally and externally. There had been no changes to the lay out of the home since the last inspection. The manager confirmed that programmes of maintenance and repair were monitored and effectively addressed in the home’s budget and that programmes of decorating had been carried out since the last inspection. This included some bedrooms and the lounge area. The manager stated that plans were in place to renew carpets on corridors. Communal areas are located on the first floor in two facilities. One of the lounges has a balcony overlooking the local golf course. The home continues to be well maintained in terms of décor, cleanliness and was free from offensive odours. Bedrooms are suitably furnished and personalised by residents. On inspection of the premises it was noted that the The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 16 door to bedroom 3 required adjusting to ensure it shut effectively into its frame. It was noted that some residents who choose to remain in their rooms, like to have the door left open. As a result some doors were being wedged open. This practice presents a serious risk in the event of a fire. The practice must be monitored and evaluated in the homes fire risk assessment. It was recommended that the home seek further advice from the fire service regarding provision and location of additional fire route signing in the home. This had been identified in a previous report by the fire service and on touring the building it was evident that some additional evacuation route signs were required. In one resident’s room a second door is used in the event of an emergency as a through route for evacuation. The resident in the room was aware of its function and confirmed that it is not used as a through route outside of emergency situations. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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 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 and 30 The home was well managed and residents benefited from a staff team that were skilled, trained and supervised. The staff team were stable and offered residents the support necessary to address and meet their needs. EVIDENCE: The staff team consists of a registered manager, deputy manager, four senior care assistants and seventeen care staff. No ancilliary staff are employed at the home. Care staff continue to undertake domestic and cooking duties in the home. The rotas for the period covering the inspection,4 to 10 July 2005, were examined and indicated that 324 day care hours were provided. These hours do not include the hours worked by the manager. The care hours provided were appropriate to meeting the needs of residents. The rotas confirmed an appropriate deployment of staff through out the week. There are up to five staff deployed in the morning, not including the manager. As stated the home does not employ domestic staff. Existing care staff have designated duties over a four week plan and evening and night staff also have designated domestic duties. The night hours are covered by two staff on waking duty and the manager was advised to designate one member of staff as senior. The manager stated that positive steps had been taken to achieve training The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 18 programmes for staff in NVQ level ll and above. Fourteen staff have achieved or in the process of completing NVQ training. The home displayed certificates achieved by staff. All certificates displayed related to staff employed in the home at the time of the inspection. The manager has achieved NVQ level IV in care and management and had recently received her certificate in relation to the registered managers award. The deputy manager is also trained to Level IV. Staff files contained the required information in relation to staffs application forms reference checks and training and development issues. Training programmes are aimed at staff achieving NVQ training and additional training programmes related to Dementia training, Managing Challenging Behaviour, Diabetic, first aid and infection control. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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 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, 33, 35 and 38 The management and administration procedures were effective in maintaining the best interests of residents and promoting their welfare. EVIDENCE: The manager holds the relevant qualifications and has experience of care of older people. The manager demonstrated a commitment to developing and keeping her knowledge current and to supporting staff on development issues. This was evident from supervision and training programmes. The relatives of residents retain responsibility for the management and administration of all financial matters. The home will make purchases on behalf of residents or pay for services such as hairdresser. An invoice will then be issued to relatives. The manager stated that issues relating to financial arrangements are discussed on admission. The home has developed a manual of policies and procedures specific to the The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 20 home. Staff indicated that they were familiar with the content of the manual from induction, ongoing supervision and support by the management team. The fire system is checked on a weekly basis. The manager was advised to monitor and ensure a weekly record of checks on the routes of evacuation are carried out. Monthly checks should be conducted in relation to the emergency lighting and fire extinguishers. The recording of a fire drill must be conducted on a six monthly basis. The manager was advised to request staff to sign the fire register to confirm their attendance. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 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 x 3 x 3 x x 3 The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 22 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 19 Regulation 23 (4) The practice of wedging doors open practice presents a serious risk in the event of a fire. The practice must be monitored and evaluated in the homes fire risk assessment. 2. 9 13 Sample signature of all staff with responsibility for administering medication msut be kept at the front of the medication administration records. 3. 19 23 The door to bedroom 3 required adjusting to ensure it shut effectively into its frame. Requirement Timescale for action 13 September 2005 13 September 2005 13 September 2005 4. The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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. 2. Refer to Standard 14 18 Good Practice Recommendations The home is advised to retain evidence of choices offered to residents at meal times. The home is advised to retain evidence that all staff have been given the opportunity to read the local Authority guidelines on adult protection. Evidence of training should also be retained. it is recoimmended that all staff sign the fire register in person to confrim their attendance at fire drills. It was recommended that the home seek further advice from the fire service regarding provision and location of additional fire route signing in the home. The night hours are covered by two staff on waking duty, the manager was advised to designate one member of staff as senior for that shift. 3. 4. 5. 38 23 27 The Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Fairways Residential Care Home F55 F05 s61019 fairways v237181 070705 stage 4.doc Version 1.40 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!