Inspection on 08/11/07 for WCS - Fairfield

This inspection was carried out on 8th November 2007.

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 27/10/06

WCS - Fairfield 11/03/06

WCS - Fairfield 10/08/05

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 West Midlands CV7 9DA Lead Inspector Martin Brown Key Unannounced Inspection 8th November 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 WCS - Fairfield DS0000004264.V344808.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. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 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 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) Warwickshire Care Services Limited Paula Dutton Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2006 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. The administrator advised that fees currently range from £392 - £444 per person per week. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been made using evidence that has been accumulated by the Commission for Social Care Inspection. The inspection visit was unannounced and took place on 8th November, between midday and 6pm. During that time, many of the residents were spoken with, as were a number of relatives visiting that day. Staff and management were spoken with, and interactions between staff and residents were observed. There were 29 residents on the day of the inspection; ten ‘self-funding’ residents, two ‘respite’ residents, and 17 residents funded by the local social services. The manager advised that the six vacancies were all for beds contracted with social services. Surveys to residents at the home and to relatives were sent out. Four were received from residents at the home, and seven from relatives of people living in the home. These were all broadly positive, with frequent compliments on the cleanliness of the home and the friendliness and helpfulness of staff. There were comments to the effect that the service could benefit from more staff. The Annual Quality Assurance Assessment, completed and returned by the manager, also informed the inspection. Policies and procedures and care records were examined, and four residents were ‘case tracked’, that is, their experience of the service provided by the home, was looked at in detail. Staff, management and residents, were welcoming and helpful throughout the inspection. What the service does well: The home continues to provide a spacious, well laid out, and pleasant environment appreciated by the people who live there. Residents and relatives were generally very positive concerning the staff, who were all professional, well-motivated and friendly throughout the inspection. The service still retains a ‘homely’ feel, helped by being divided into smaller, named areas, such as ‘Rowan’ and ‘Cedars’. Residents continue to be pleased with the home, and ‘glad that they come to this home’. Staff were singled out for praise, with ‘friendly, helpful, and caring’ being typical comments. Relatives also praised the home in completed questionnaires: “My mum’s been in a few care homes and I think this is the best. The care at this home is very good,” was one comment. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 6 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 summary of this inspection report can be made available in other formats on request. WCS - Fairfield DS0000004264.V344808.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 WCS - Fairfield DS0000004264.V344808.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): 2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents moving to the home can be confident that their health and support needs have been assessed and that the home is able to meet them, and that the home gathers details of life history, interests, likes and dislikes, to help provide an individual service. EVIDENCE: Files for two recent admissions were looked at. These contained assessments, and included life histories, on the organisation’s own pro-forma. These help inform the staff not only of needs, but also of areas of interest and discussion. Those looked at were written in the first person, but done by someone other than the person whose life history it was. The manager was advised that it may be useful, for future reference, for such life histories to indicate who has written them, and when. A relative of one recent admission was spoken to, and she was keen to say how helpful the service had been during a difficult time, and how the service had not only resolved problems, but had also ensured that they were fully informed of solutions. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 9 The service has two respite beds. These are not used for rehabilitative care; rather they provide regular respite to meet particular needs, or may take suitable emergency respite cases. Some residents had commented in questionnaires on not having contracts; sample files looked at showed contracts in place, and the manager showed copies of new, clearer contracts that were being introduced, and was confident that these would help individual awareness of contracts. Several residents spoken with commented that they left things such as contracts for their relatives, as what concerned them was that they got what they needed in the home on a day-to-day basis, and the overwhelming reaction from those spoken with was that this was the case. Service User Guides and a Statement of Purpose were seen to be available. The manager advised in the Annual Quality Assurance Assessment that these were to be reviewed, and wished to make them more readily available in other formats, so that they would also be available via the internet. WCS - Fairfield DS0000004264.V344808.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with dignity and respect, and health needs continue to be met in line with regularly reviewed care plans. The administration of medication is much improved, and residents can be confident that minor shortcomings in recording medication will be promptly rectified. EVIDENCE: A sample of four individual care plans was looked at. Others were looked at to follow up individual issues that arose during the inspection. These are designed by the organisation to be comprehensive throughout all its service, and included life histories, health and social care needs, and showed evidence of being regularly reviewed. They highlighted where needs indicated specific risks, and how this was managed; as with, for example, someone known to be ‘at nutritional risk’ being encouraged and supported to eat at any time of the day or night. Where risk management requires additional detail, there are separate risk assessments included in the care file. Where one person had had swallowing problems this was properly managed, with recording showing the involvement of appropriate professionals, diet and medication instruction following hospital advice and finally, action agreed by the GP following the WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 11 person’s declaration that she could take medication in capsule form again. The only shortcoming noted was that the clear advice on how this medication should be taken whilst swallowing difficulties persisted was not signed or dated, which could potentially lead to uncertainty as to whether the advice was still current. The manager was keen to show the workings of the new care management system, whereby health and care needs were regularly reviewed and scored to inform any necessary changes in meeting care requirements, to ensure, in the words of the Annual Quality Assurance Assessment, ‘a prompt and appropriate response’. Medication systems have been reviewed following a number of requirements at the previous inspection, and the overall practice of medication administration and recording was much improved. Staff were observed, as previously, to administer medication professionally and sensitively. Recordings tallied with administration of all regularly prescribed medication. Audits of medication regularly take place to check that amounts of medication remaining tally with those dispensed. An area of inconsistency had been noted by management, where some ‘PRN’ (‘as required’) medication had been given in variable amounts, according to need and in line with medical guidance, but the amounts given (e.g.: one or two tablets) were not recorded. Clear recent guidance was seen regarding this, but a check on some recent PRN medication confirmed that this was not consistently happening, with a lack of clarity in two recordings noted. The manager agreed to look afresh at ensuring that amounts administered for such medications, where variable dosages are permitted, are accurately recorded. There was an inconsistency noted that had not been picked up by the home, between printed guidance concerning storage given by the pharmacist, and that given by the manufacturer, on a box containing eye drops. The manager immediately requested, and was given, clarification from the pharmacy on this matter. All Medication Administration Record Sheets looked at contained photographs of the individual residents. The ‘blister pack’ system also contained space for photographs of each resident. The manager agreed that putting photographs on these as well could be an additional safeguard against any mistake. There is at present only one fridge suitable for storing medication requiring such storage. At the time of the inspection, there was one medication in use downstairs that had to be stored in this fridge, which was upstairs. One resident had responsibility for self-medicating one particular medication, and this was recorded appropriately. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 12 Staff interactions with residents continue to be positive. Staff were friendly, warm and helpful whenever observed, and supported residents in maintaining dignity and privacy by being respectful and discreet at all times. Comments both on the day, and in questionnaires, from residents and relatives indicated this was always the case. Several residents said that they prefer to spend a lot of time in their own rooms, and did so, knowing that staff would be available to help whenever called upon or needed. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in maintaining contacts with relatives and friends, are helped to exercise choice, and are able to satisfy expressed social, cultural, and religious needs. A choice of healthy food also caters for special dietary needs, and is enjoyed in a variety of smaller dining rooms. EVIDENCE: All residents spoken with expressed satisfaction with the level of activities, most commenting that they occupied themselves much of the time. Several commented that, while there were activities on offer, within and occasionally outside the home, they preferred to occupy themselves, reading, listening to music, watching TV or listening to the radio. Residents spoke of activities being offered, such as trips out, and bingo, which they were free to take up or not, as they wished. As noted at the previous inspection, many residents spent a lot of time in their rooms, and appeared content to do this, knowing that staff are available if needed. In this respect, the home for some residents continues to bear positive similarities to a sheltered housing complex, with residents valuing their privacy and security, and many only using communal areas at mealtimes. Many residents have a regular paper delivered. Staff were seen promptly WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 14 distributing to rooms one tabloid that had been delivered late by the newsagent. Staff showed a good awareness of which residents benefited from greater time and attention. Life histories enable staff to pick up on residents’ individual interests. Arrangements were in place for a more recent admission to have her religious needs met. Responses from relatives in questionnaires were broadly positive, with praise for staff’s approachability and helpfulness. One commented that they sometimes had to wait for a member of staff to let them in. This has been alleviated in the weekdays, at least, by moving the administrator’s office to the front of the building to also serve a receptionist’s function. A visitor spoken to during the inspection was very positive about how supportive and open the home was. Mealtimes were observed to be a relaxed, and easy-going time, with staff discreetly offering help as required, with freshly-prepared hot meals available in the day time, and a choice of snacks in the early evening. Meals are taken in a number of smaller dining rooms, corresponding to the way the home is divided into distinct ‘units’. One returned questionnaire had written ‘food could be better’ but all other comments received about the food were positive, with ‘very good’ and ‘excellent’ being typical. Special diets are catered for, and detailed lists of preferences and dislikes assisted staff in catering for individual needs. The manager advised that the service was entering for the local ‘Healthy Heartbeat’ award. She gave examples of choices, such as pasta, being offered, but not being popular with residents. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse, and they and their relatives can be confident that complaints will be listened to and acted upon. EVIDENCE: The manager said that the home had received two complaints since the last inspection, and was able to show that these had been investigated and responded to satisfactorily. All questionnaires completed and returned by residents indicated that they were aware of how to complain if they wished. All residents and relatives spoken with during the inspection either said that they either had no concerns or were confident in raising any concerns with staff or management. Questionnaires returned, as well as comments on the day by residents and relatives, all showed very positive comments on the staff and management, such as ‘the staff are very friendly, helpful and caring’. A ‘review’ meeting at the home, at which the chief executive of the organisation would be available to answer queries concerning the service was advertised to take place at the home shortly. Staff spoken with had undertaken abuse training, showed a good awareness of abuse, and of the appropriate action to take in the event of abuse being suspected or reported. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents continue to benefit from a clean, pleasant, well-planned environment and the division of a large home into smaller, more ‘homely’ units. They can be confident that maintenance and refurbishment will continue to take place to ensure the quality of the environment is maintained and improved. Residents safety is compromised if a fire risk assessment does not clearly address all the issues of fire safety, particularly the safety of fire doors to residents’ rooms being left open. Residents can be confident that the manager will address this promptly and ensure residents’ safety by completing the home’s fire risk assessment to include specific details on where automatic closures on fire doors are needed, or not needed. EVIDENCE: The home was clean, pleasant and free from any unpleasant odours on this unannounced inspection, and continues to benefit from being several smaller units, with smaller, more ‘homely’ dining rooms and lounges. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 17 A ‘kitchenette area has been refurbished, one small lounge is in the process of being made more ‘homely’ and suitable for purpose. The reception area has been refurbished, enabling the administrator to be situated there and offer a welcome there during ‘office’ hours. Residents and relatives were complimentary concerning the décor of the home. Staff spoken with were pleased with the money that was being spent on refurbishing areas of the home. Residents spoken to in their rooms were happy with the décor and had personalised them to make them more homely according to their wishes. One feature spoken of very positively by several residents is the outlook. All rooms either overlook the garden, or have a commanding view towards Birmingham. There is an outdoor covered area where anyone who wishes to smoke can go. Bathrooms and toilets were all clean and tidy. One resident had queried in a questionnaire as to greater availability of raised toilet seats. These are available in some toilets. One bathroom had a small corner section loose near the floor. The manager advised that there had been problems with the hot water system, and plumbers had been ensuring that ‘mixing’ valves were all working correctly, after the failure of some of them. Water temperature charts were being kept regularly. The manager was fully aware that these were particularly important if there was any doubt about the effectiveness of ‘mixer’ valves in ensuring temperatures were always at a safe level. Examination of water temperature records showed that temperatures were all recorded as being maintained at a safe level. There were no concerns expressed regarding the laundering of clothes, and the laundry continues to operate satisfactorily and hygienically, as observed at the previous inspection. Residents’ doors do not have closure devices on; the manager advised that this was not highlighted during a visit by the Fire Officer. There are fire doors with magnetic closures at intervals along corridors. This was not noted as part of any fire risk assessment. The manager advised she will clarify this with the Fire Officer, take any action necessary, and ensure it is clearly recorded in the fire risk assessment. She took action to establish contact in respect of this during the inspection. Staff showed a good awareness of appropriate action in the event of the smoke alarms sounding. Organisational fire safety policies indicated that it expected residents’ bedrooms to have closure devices on. There was furniture stored at the top of two stairways. These were not the main stairways, and the furniture did not pose a direct obstruction. Nevertheless, they posed a potential hazard, and the manager agreed that they should be disposed of, rather than added to. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing is sufficient to meet service users’ needs, which is done in a respectful, warm, and friendly manner, much appreciated by residents and relatives. A more consistent approach to induction recently introduced should ensure that all staff can more rapidly achieve and demonstrate the required level of competence. EVIDENCE: Rotas and staff numbers on duty indicated sufficient staff to meet the needs of current service users. While several comments on returned questionnaires showed a perception of the staff being busy at times, those spoken with during the inspection were all happy with the level of staff support and availability. “There are always enough staff, and people around to check on things” was a typical comment. One relative had commented that they sometimes had to wait for the front door to be answered when they visited. The availability of a person on reception during ‘working hours’ helps to alleviate that problem at these times. The relative queried whether a ‘keypad’ with a number code given to relatives, could be used, as in some homes. This query, with obvious security implications, was not raised with the manager during the inspection. Amongst many very positive comments by residents and relatives concerning staff ‘friendliness’ ‘caring’ and helpfulness’, one relative commented that they WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 19 couldn’t be sure what staff’s qualifications and skills were. The service has gone some way to addressing this on a day-to-day basis by issuing all staff with badges, giving their name and job title. Recruitment files of the two most recent staff were examined. Criminal Records Bureau checks, Protection of Vulnerable Adults checks were seen to be in place, as were complete application forms and references. One reference for one employee was poor. the manager was able to satisfactorily explain the background for this, along with some brief notes concerning the issues. I advised that such records would be best kept attached to the reference, for clarification in case of future queries. The manager further advised that negative comments on the reference had proved to be, on the employee’s performance in the home, unjustified. A number of staff had an ‘in house’ training session during the inspection, and were able to discuss the benefits of it afterwards. One staff expressed concern that the home was poorly staffed during the duration of the training. There were a number of staff remaining on duty who felt confident numbers were sufficient, and said they could call staff out from the training if necessary. Copies of certificates evidenced ongoing training, the Annual Quality Assurance Assessment detailed ongoing National Vocational Qualification level 2 training for staff. Staff comments concerning training were favourable, ‘they’re very good here at providing training’ being a typical comment. The manager acknowledged in the Annual Quality Assurance Assessment that induction had not been delivered consistently, but was able to show a new induction record, that has now been introduced and which, she advised, is currently being used by the most recent recruits. The induction record was very comprehensive, aiming to measure not just instruction received, but understanding of it and competence in applying it. All observations during the inspection showed staff helping residents in a warm, friendly and respectful way, with dignity being maintained by discreet responses to personal care issues. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well-run home that is run in their best interests, and in which their health, safety and welfare is promoted. EVIDENCE: The area manager was making a ‘regulation 26’ visit on the morning of the inspection. Records of these were seen, which feed in, with consultation with residents, to the annual review of the service. A poster on the wall advertised the visit of the chief executive of the organisation as part of this annual review of the service, giving an opportunity to residents and relatives to offer their views directly. The results of the annual review, along with the business plan are then available for those who wish to WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 21 see these. Residents spoken with were more concerned with the direct impact of the service upon their well being, and were generally complimentary in all aspects of this, most notably the friendliness, helpfulness and availability of staff, and the cleanliness and pleasantness of the surroundings. The administrator evidenced the accurate recording of monies kept on behalf of residents, with monies kept individually, with expenditure clearly receipted, and regularly audited. Residents have secure places to any monies or valuables in their rooms if they wish, and can lock their rooms if they choose. The relocation of the administrator’s office to the reception area enabled visitors to be greeted and immediate queries resolved. One relative spoken with commented very favourably concerning the work and helpfulness of the administrator. The safe maintenance of water temperatures has been noted in the ‘environment’ section, as has issues concerning fire safety. The Annual Quality Assurance Assessment completed and returned by the manager showed all necessary safety checks of equipment taking place. The lift between floors gives audio safety advice to assist those using it. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 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 3 x 3 x 3 x x 2 WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? no 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 OP9 Regulation 13(2) Requirement The service must ensure that, where ‘as required’ medications allow for variable dosages to meet need, the amount dispensed each time is accurately recorded. The fire risk assessment for the home must detail any implications that residents’ bedroom doors being open has for fire safety, and the service must take any action necessary to ensure residents’ safety in the event of fire. Timescale for action 20/12/07 2. OP19 OP38 23(4) 20/12/07 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 It would be helpful for life histories or similar notes to be signed and dated, in case any elements are needed to be followed up. DS0000004264.V344808.R01.S.doc Version 5.2 Page 24 WCS - Fairfield 2. OP9 3. 4. 5. 6. OP9 OP9 OP19 OP27 Putting individual photographs in the space provided on ‘blister pack header cards, as well as on the Medication Administration Record Sheets headers, would be an additional safeguard against error. Two fridges for storing medication would mean staff would not have to go from one floor to another to get any such medication. All guidance regarding the administration of medication should be signed and dated, to facilitate reviewing of it. Discarded furniture should be disposed of, so as not to become a potential hazard. It is recommended that the service reviews why some people may feel that there are not enough staff at times. WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 WCS - Fairfield DS0000004264.V344808.R01.S.doc Version 5.2 Page 26 - 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!