Inspection on 10/08/05 for WCS - Fairfield

This inspection was carried out on 10th August 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

WCS - Fairfield 08/11/07

WCS - Fairfield 27/10/06

WCS - Fairfield 11/03/06

WCS - Fairfield 30/11/04

WCS - Fairfield 07/06/04

WCS - Fairfield 11/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE WCS - Fairfield Butler Crescent Exhall Coventry CV7 9DA Lead Inspector Patricia Flanaghan Unannounced 10 August 2005 11:00 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. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service WCS - Fairfield Address Butler Crescent Exhall Coventry West Midlands CV7 9DA 02476 311424 02476 490018 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) Warwickshire Care Services Limited Mrs Sheila Angela Archer Care Home 35 Category(ies) of Old Age - 35 registration, with number of places WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30 November 2004 Brief Description of the Service: Fairfield is a former Local Authority, purpose built home for older people. Situated on a large housing estate in Exhall, it lies between the town of Bedworth and the city of Coventry, and is close to local amenities such as shops, pubs and a ‘bus route’. The home has good parking, and landscaped gardens to the front and rear of the building. The home is on two floors and is organised into five units. The home is staffed over 24 hours by a management team, carers and ancillary staff. Nursing care is not provided, but service users who require the attention of a nurse can access one through the community nursing service, as they would if living in their own homes. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection and took place over one day between the hours of 11:00 am and 5pm. This was the first visit for this inspection year. Staff co operated fully with the inspection. The care manager was present throughout the inspection. The inspection process involved a tour of the home, talking with the care manager, examining records and care plans, observation of care practices along with discussions with residents, staff and relatives who were visiting on the day of the inspection. What the service does well: 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. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 6 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 WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 7 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 All service users have an assessment of their needs prior to their admission to Fairfield assuring them that their needs can be met by the home. The absence of up to date care files of newly admitted residents however mean that it is not possible to say that all care needs are met for all residents. EVIDENCE: All potential residents are assessed before being offered a place in the home and five pre-admission assessments were seen and examined. Not all of the assessments reviewed had been signed and dated. Two of the files examined related to residents who were known to staff having been in the home previously on respite. The care plans for these two residents had not been updated since their previous stay in the home, although the new pre-admission assessment indicated that their needs had changed. The home does not provide intermediate care. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 8 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 and 10 Care plans require review to provide the staff with the necessary information to meet individual residents needs. Without this review there is the chance that aspects of residents’ care may not be fully attended to. Health needs of residents are met with evidence of liaison with health and social care professionals on a regular basis. Residents were treated with respect and their privacy and dignity were promoted enhancing their wellbeing and self esteem. EVIDENCE: The organisation has developed comprehensive individual plans of care identifying the health and personal care needs of residents. Staff have received training and it was advised that this training is ongoing. Five care plans including those of two recently admitted residents were examined. Daily entries in care records identified changing care needs although this was not always reflected in resident care plans. For instance, one daily record advised that the resident prefers to sleep in day clothing, however, this was not identified in his “resting and sleep” care plan. An entry for another resident stated that they had been “…shouting out…” and that it “sounded really scary”. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 9 There was no further entries relating to this incident and no evidence that any action had been taken to direct staff on how to deal with this situation if it occurred again. One of the files reviewed had not had a daily entry since 31 July – 10 days previous to this inspection. Two recent admissions to the home were known to the staff through day care and had lived previously in the home for a short period. Up to date preadmission assessments had been undertaken, but the staff were still using the care plans developed for earlier admissions although it was clear the care needs had changed. For example, a resident admitted in July 2005 was being cared for according to a plan developed in April 2005. The April “continence care plan” advised that the resident is “fully continent and will use urine bottles during the day” however, the pre-admission assessment in July identified that a catheter was now in-situ. There are places in the care plan files for staff to record personal care given, however, it was noted that the last documented bath/shower for one of the residents was on 8 July and there were no entries on the file of anther resident. The nutrition care plan for a recently admitted resident was blank, although the pre-admission assessment identified that the resident had haemorrhoids. A Care Summary Sheet is completed following a full assessment. There were no dates recorded on the summary sheets examined to indicate when these had been completed. Discussions with care staff evidenced that they are aware of the care needs of residents, however, the lack of written information could result in all care needs not being identified and therefore the omission of care. Records seen combined with discussions with the residents, visitors and staff demonstrated that the home is pro-active in protecting the privacy and dignity of residents. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 10 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 and 14 Residents were satisfied with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Contact had been maintained with relatives and friends of residents. Opportunities to access the local community had been made available. EVIDENCE: Visitors are welcome at the home and information is available in the home’s brochure of visiting arrangements. A number of visitors confirmed that they are always made welcome by staff and offered a drink. The programme for activities include regular outings. Activities include Music and Movement, board games, reminiscence, quizzes and bingo. Residents can partake of activities in the day care facility or can remain on their own unit where up to date information regarding activities is displayed. All residents spoken with felt there were sufficient activities offered by the home. Residents said that they could choose how they spend their day and could take part in the social activities if they wished to. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 11 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) These standards were not assessed as part of this inspection. EVIDENCE: WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 12 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, 23 and 24 The home provides a safe and pleasant environment, which is well maintained, for residents to live comfortably with suitable facilities to meet their needs. EVIDENCE: There are well-maintained enclosed gardens for residents to enjoy. A small number of residents enjoy helping in the garden and it was evident that a lot of work had gone into making the gardens a pleasant area to sit or walk in. The weather was warm during the visit and a number of residents were seen to sit outside enjoying the sunshine. A tour was undertaken of the home. All interior areas were found to be clean and generally well maintained. The home has an ongoing refurbishment programme both for bedrooms and communal areas. There are a number of communal lounges throughout the home. Furnishings and fittings are domestic in style enhancing the homely atmosphere. Residents are encouraged to bring personal items in with them and can furnish and redecorate their private room to their own taste if they wish. Personal possessions were noted in the bedrooms viewed during the inspection visit WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 13 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 employs sufficient trained and competent staff to meet the needs of its residents. EVIDENCE: The staff duty rotas for the period of a month were reviewed. These demonstrated that staffing numbers were being maintained within agreed levels. It was observed during both days of the inspection visit that the skill mix of staff was sufficient in meeting residents needs and there were suitable numbers of experienced and trained staff on duty. There are five care staff on duty during the day. The care manager works supernumerary hours to those of the care staff. At night there are two waking night staff and an emergency on call system in place. In addition to this the home employs domestic, kitchen and laundry staff. All residents spoken with confirmed that the staff are friendly and attentive to their needs. Records indicated that 15 of the 26 permanent care staff employed at the home have, or are in the process of completing an NVQ level 2 and three staff members are working towards an NVQ Level 3. Training records were examined which demonstrated that staff have regular training on the diseases and illnesses associated with old age ensuring they are competent to do their jobs. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 14 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) These standards were not assessed as part of this inspection. EVIDENCE: WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 15 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 x x 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 x x x x x x x x x x x WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 16 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 3 Regulation 14 Requirement The manager must ensure that a comprehensive pre admission assessment is completed for all prospective residents to ensure that their needs can be met. Meaninful care plans must be developed from this initial assessment. The registered manager must ensure that each resident has a care plan. Care plans must set out in detail the action needed to be carried out to ensure that all aspects of the health, personal and social care needs of each resident is met. Care plans must be up to date and reflect the current needs of individual residents. These must be reviewed monthly as a minimum. Timescale for action 30 October 2005 2. 7 15 30 October 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 17 WCS - Fairfield 1. WCS - Fairfield E53 S4264 WCS - Fairfield V244441 100805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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. 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