Care Home: Fairview

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What the care home does well Generally the home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the home was noted to be relaxed. Residents looked well cared for in their homely environment. Staff were noted to be interacting with residents in an informal, respectful, personalised and dignified manner. Prospective residents are assessed before admission to the Home and the Home ensures that a Service Users Guide is given to them to enable them to make an informed choice about moving to the Home. Residents and relatives are informed on admission about the one-month trial period to enable them to make a decision whether to stay. In order to ensure adequate nutrition for residents, good meals are provided and are not hurried; those who have difficulty with feeding themselves are assisted as required.FairviewDS0000034844.V375944.R01.S.docVersion 5.2The Home provides meaningful and stimulating activities for its residents and ensures that individual interaction is provided as a routine and as necessary. The manager stated that the residents are comfortable with raising concerns and complaints and are assured that they will be listened to and their views acted up on. An effective staff team who are well supported by the senior management team supports residents. It was evident from the staff interaction with the residents` and the records seen that there is a warm relationship between the staff and the residents at the home. What has improved since the last inspection? Danella Daniels has been in post as the new manager for Fairview House residential Home since September 2008. The manager stated at the inspection that the home had implemented new ways of auditing the medication in order to prevent errors to residents. Other improvements she has made include:Arranging Community transport links for the residents to use to provide more involvement in the local community. Lounge area had been redecorated and softer lighting and furnishing updated. New en-suite added to a bedroom. New carpet and flooring in some bedrooms Staff training have been updated in Protection of Vulnerable Adults and Whistle Blowing. A new cleaner had been employed to enable 2 cleaners on a 7day rota. A new senior carer had been employed to compliment the management team Changes to night staff had been made following disciplinary action. What the care home could do better: The home must ensure that staff are adequately trained to ensure that any medication not given is not signed for. All required information in relation to a resident`s care on admission must be completed in their file to support staff in meeting the needs of the individual.FairviewDS0000034844.V375944.R01.S.doc Version 5.2 The home must ensure risk assessments are in place and regularly reviewed following a fall. Auditing the accidents to residents will enable the home to establish if there is a pattern in order to put appropriate risk assessment in place and update the care plans. We noted that the present facility for storing residents` monies is not entirely safe and we have recommended that the home seek alternative storage to ensure that residents` monies and other belongings are secured. Key inspection report CARE HOMES FOR OLDER PEOPLE Fairview 42 Hill Street Kingswood South Glos BS15 4ES Lead Inspector Grace Agu Unannounced Inspection 18th June 2009 09:00 DS0000034844.V375944.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairview Address 42 Hill Street Kingswood South Glos BS15 4ES 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) 0117 9352220 0117 9476234 jackiereed@btconnect.com Mrs June Phillips Mr Gordon Norman Brooking, Mr Derek Marsh Manager post vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category(Code OP) The maximum number of service users who can be accommodated is 24 25th July 2008 Date of last inspection Brief Description of the Service: Fairview is situated in a quiet cul-de-sac in Kingswood and is close to local shops and amenities. Private parking is available in the front of the house. The home is registered to provide personal care and accommodation for up to 24 persons who are over 65 years of age. The home is an older property arranged over three floors. There is a large communal space separated into a lounge and dining area. Bedrooms have been refurbished. There is a shaft lift servicing all floors except for bedrooms 20 and 21. These two rooms are accessed by a small flight of stairs and can only be used by ambulant residents. The cost per week to reside at Fairview will range from £348.00-£480.00. Fees are reviewed annually and if care needs increase. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This is an unannounced inspection, which took place over eight hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection two requirements were made in relation to medication administration practices and ensuring that identified hazardous flooring was replaced and that risk assessment had been undertaken to ensure that the person living in the room is safe from accidents. It was pleasing to note that one of these requirements had been met. A tour of the building was undertaken and a number of records were viewed. Thirteen residents, two relatives and three staff members were spoken with on the day. At the end of the visit we discussed some of the outcome feedback with the new manager Danella Daniels and Mrs Gill Evans the group manager of the organisation. What the service does well: Generally the home was found clean, warm, well lit and free from unpleasant odours. The atmosphere of the home was noted to be relaxed. Residents looked well cared for in their homely environment. Staff were noted to be interacting with residents in an informal, respectful, personalised and dignified manner. Prospective residents are assessed before admission to the Home and the Home ensures that a Service Users Guide is given to them to enable them to make an informed choice about moving to the Home. Residents and relatives are informed on admission about the one-month trial period to enable them to make a decision whether to stay. In order to ensure adequate nutrition for residents, good meals are provided and are not hurried; those who have difficulty with feeding themselves are assisted as required. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 6 The Home provides meaningful and stimulating activities for its residents and ensures that individual interaction is provided as a routine and as necessary. The manager stated that the residents are comfortable with raising concerns and complaints and are assured that they will be listened to and their views acted up on. An effective staff team who are well supported by the senior management team supports residents. It was evident from the staff interaction with the residents’ and the records seen that there is a warm relationship between the staff and the residents at the home. What has improved since the last inspection? What they could do better: The home must ensure that staff are adequately trained to ensure that any medication not given is not signed for. All required information in relation to a resident’s care on admission must be completed in their file to support staff in meeting the needs of the individual. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 7 The home must ensure risk assessments are in place and regularly reviewed following a fall. Auditing the accidents to residents will enable the home to establish if there is a pattern in order to put appropriate risk assessment in place and update the care plans. We noted that the present facility for storing residents’ monies is not entirely safe and we have recommended that the home seek alternative storage to ensure that residents’ monies and other belongings are secured. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 8 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 Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The process of admission of prospective residents is, detailed and well planned to enable the residents to make an informed choice of moving to the home with the assurance that their needs will be met. EVIDENCE: The home’s Statement of Purpose and Service Users Guide is to be reviewed to include the name of the new manager. The document contained other relevant information as required by the regulations. These documents are readily available to prospective residents and their representatives when they visit or make enquiries to enable them to make an informed choice of moving to the Home. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 10 Discussion with the manager confirmed that two recently admitted residents were assessed before admission to the home to ensure that the home is able to meet their needs. One resident confirmed that their relative visited the home before they were admitted. The individual said that they were made aware of one-month trial period to enable them to make a decision to stay at the home permanently. The home manager stated that all residents receive terms and conditions of their stay as a part of the admission process. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home offers care and support to residents throughout their lives and towards the end however, it protects residents by reviewing their health needs and appropriate care planning. The home must ensure that safe medication administration and storage practice is satisfactory at all times. EVIDENCE: Two care files were reviewed at this visit. Evidence from the care files show that residents are assessed on admission before care plans are written. The records seen on one of the care files were able to give staff clear information on how individuals at the home are supported in areas of personal Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 12 care as well as individual’s social, emotional and physical support. These are followed up by monthly reviews and intervention as needs change. However we were concerned that the other care file viewed had some relevant forms in regards to the care of the individual that were not completed to ensure that the needs were met. The forms include dependency level, nutritional assessment. Furthermore we noted that the individual had a fall on 25/05/09, this was not recorded in the accident book, and there was no risk assessment and care plan in place to prevent the individual from further falls. We have issued requirements in relation to those concerns mentioned above. Examination of care documentation evidenced that residents are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and General Practitioners. A group of residents, met in the lounge, told us that they like living at Fairview and that the staff are very good. One resident met in the room states “they listen to me; they answer the bell when we call. I have a choice of when I get up and when I retire”. Another resident said, “The girls are very respectful, they treat us well”. One relative stated “My relative had to come because they were so ill” They feel much better.” Medication administration was reviewed and it was pleasing to note that the requirements made in relation to medication administration malpractices at the last inspection had been fully met. It was also noted at this inspection that a medicine policy was in place, there was evidence of receipt and disposal of medication, Controlled drugs were properly recorded and signed by two trained staff members and balances were correct. A local pharmacy provides medication using a monthly monitored dosage system. All medication seen was stored securely. A Medicines trolley is used to transport medication around the home. One Staff member spoken with was aware of measures to be taken if a resident became terminally ill and in the event of death. Evidence of residents’ wishes in the event of death was noted in the care files. One resident who is terminally ill stated that she was treated with dignity and respect during a recent illness. A family member of this person met on the day stated that they were satisfied with the care provided to their relative. The Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 13 individual stated “Mum has been ill the last few months with a medical condition and its side effects. The care that the home has provided has been outstanding, going well beyond that to be expected” The care file of the resident contained records of referral and visits from the hospice nurse and district nurses to work with the home to provide care and pain control for the resident. The home has Death & Dying policy. The staff also demonstrated awareness of the importance of ensuring that information about residents is kept confidential. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are enabled to maintain links with their families and are also provided meaningful activities. The food is nutritious with varied choices available. EVIDENCE: On the day of inspection residents were noted relaxing in the lounge and enjoying the company of each other, some residents were noted sitting in their bedrooms other residents were also observed interacting with staff accessing different areas of the home without restriction. One resident met in the bedroom stated that staff were always there and would attend to her needs in emergency and that they are satisfied with the care provided at the home. The home has an Activity Coordinator who ensures that as many residents as possible participate in the activities organised by the home. The person told us that there are three staff in the team shared between the sister home in the adjacent premises owned by the same organisation. The team spends three Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 15 mornings a week and two afternoons at the home to ensure that the residents have adequate stimulation throughout the week. Activities provided include exercises, arts and craft, memory games, bingo sing-a-long, puzzles and one to one for people in their rooms who decide not to participate in the group activity. Other entertainments provided include Strawberry Tea in the garden on 13/06/09, keyboard player 17/06/09., and trip to Chew Valley Lake on the day of the visit. Planned activities include trip to the Beach and Seaside with Kingswood Community Transport on 25/06/09 and Paddling Pool for those unable to attend the Seaside trip, Punch and Judy Show on 22/06/09, dress for beach show, games and treasure hunt on 24/06/09. The Activity Coordinator stated that the home has regular monthly Church of England service for the residents who actively seek to maintain their faith. A priest is invited regularly to administer Holy Communion to a person of a different religious belief. A volunteer is to be arranged to accompany the individual to attend services in a local church. To strengthen the relationship between the home and the community and to support the residents who practice their faith, the local vicar visits once a month to offer full church service and Holy Communion and would visit midweek sometimes on request. On the day of this inspection, residents were supported to go on a trip to Chew Valley Lake. The activities book reviewed, identified residents who participated in activities and those who declined but preferred to watch. The visitors’ book showed that the relatives and representatives regularly visit the residents. Residents spoken with stated that they had regular visitors. The lunch on the day looked nutritious and balanced and the residents spoken with stated that they enjoyed their meal. Staff were noted interacting with residents in a respectful manner whilst assisting them with their lunches. The kitchen was found clean and staff had attended basic food hygiene training to ensure that the residents are adequately protected. There was evidence of regular recording of fridge, freezer and food probing temperatures. The certificates for basic food hygiene updates for the kitchen staff were noted displayed in the kitchen Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 16 A recent report in relation to the visit from the Environmental Services was noted to be good. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are enabled to complain and are protected from abuse through appropriate policies and procedure. EVIDENCE: The home’s complaint procedure contains required information and details of how to contact the Commission for Social Care Inspection if they were not satisfied with the outcome of their complaint. The complaint procedure was displayed at the entrance of the building. The document was also seen in the Service Users Guide and in residents’ care files. There were two recorded complaints since the last inspection. In each case the complaint was investigated and action taken to ensure that the concerns were not repeated. However the manager stated that one complaint had been forwarded to Social Services by a relative as they were not satisfied with the outcome of the home’s investigation. One new staff members’ file reviewed evidenced that two satisfactory references and Criminal Record Bureau Disclosures had been obtained before commencement of employment. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 18 Evidence from speaking to staff and the manager showed that the home has made efforts to ensure that staff members receive training on Protection of Vulnerable Adults from Abuse in order to protect the residents. The home has a policy and guidance on the Prevention of abuse as well as the South Gloucestershire Council policy on reporting incidents of suspected abuse. The home also has a Missing Persons policy to ensure that staff are aware of actions to be taken if a resident’s safety is compromised. Residents spoken with stated that they felt safe at the home. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24.25,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents enjoy a suitable, safe and well-maintained environment EVIDENCE: Fairview is situated in a quiet cul-de-sac in Kingswood and is close to local shops and amenities. Private parking is available in the front of the house. The home is registered to provide personal care and accommodation for up to 24 persons who are over 65 years of age. The home is an older property arranged over three floors. There is a large communal space separated into a lounge and dining area. Bedrooms have been refurbished. There is a shaft lift servicing all floors except for bedrooms 20 and 21. These two rooms are accessed by a small flight of stairs and can only be used by ambulant residents. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 20 A walk about the home and evidence gathered from residents, staff and visitors created an impression of a comfortable suitable and well maintained home. It is generally light and bright and very attractively decorated with beautifully laid out gardens. Residents’ rooms seen during the walk about looked clean and pleasantly tidy with significant variety of personal belongings displayed and in use. The rooms appeared well maintained and domestic in the style of decoration. It was pleasing to note that many floorings in residents rooms had been replaced including the one identified at the last inspection. The homes’ maintenance book showed that the hot water temperature checks were up to date. Other environmental health and safety requirements were satisfactory. The home was found fresh and clean throughout and there is an Infection Control Policy in place. Staff were well presented in their uniforms and had aprons when serving food and assisting residents with personal care. The laundry was noted to be clean; we noted that there were sacks of clothing in the laundry due to break down of the washing machine. The Group Manager Gill Evans told us that the clothing had been taken to one of the sister homes for washing while waiting for the arrival of the engineer to attend at Fairview Care Home. Clinical waste, if generated, is disposed of effectively. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s recruitment process demonstrates safeguards are in place, and also ensures staff competency, there are adequate numbers of staff along with training to protect the residents. EVIDENCE: The manager told us that the staffing level is satisfactory and meets the needs of the residents as confirmed by the current rota. Everyday from 8am to 2pm the manager and three carers are on duty and are supported by catering, cleaning and laundry staff. On night duty from 8pm to 8am there are two waking carers. The manager stated that twelve staff members have achieved National Vocational Qualification (NVQ) at level 2 and two staff members are working towards achieving NVQ at level 2. Also three staff members are working towards achieving NVQ at level 3. Other training undertaken by staff include basic food hygiene, manual handling, infection control and Protection of Vulnerable Adults. The home has a robust recruitment procedure to ensure that suitable staff are recruited to meet service user’s needs. The records of two recently recruited Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 22 staff members contained required information to include personal details, previous employment details, two satisfactory references, Criminal Record Bureau (CRB) disclosures and relevant qualifications. There is a minimum staff turnover in the home. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed; it also ensures that there is adequate protection in relation to health and safety of residents, staff and visitors. EVIDENCE: Ms Danella Daniels is the new manager for Fairview House Residential Home. Ms Daniels has achieved National Vocational Qualifications (NVQ) at levels 2, 3 and 4. The qualifications and experience enable her to support staff members to provide high quality care for the residents. Danella stated that she plan to undertake the Registered Managers Award training after registration with the Care Quality Commission. Danella told us Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 24 that she had applied for registration and is awaiting invitation from the Commission for “Fit Person’s Interview”. The manager had a clear understanding of her role and responsibility within the home and was able to demonstrate understanding of the needs of the residents. There was evidence that the manager and her team were committed to maintaining good levels of service. Residents, relatives and staff spoken with on the day commented positively and highly of Danella’s ability to manage the home. Staff spoken with on the day of inspection stated “she is good, open and approachable”. Ms Daniels stated at a discussion that she is well supported by the provider and would ensure that the home is provided with adequate resources for meeting the needs of residents. There was evidence of staff meetings to ensure that staff remain focused on the vision of the home to provide quality care to the residents. At the last staff meeting on 24/04/09 issues discussed include staff rota, training and key working systems. The home has robust policies and procedures in relation to aspects of health and safety. Records relating to health and safety were clearly written and accessible to staff. There was evidence that the home takes the health and safety of residents, staff and visitors seriously whilst maximising residents’ independence. For example the home had completed a fire risk and generic risk assessments. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipment and recording of training and testing of equipment was satisfactory. Staff have attended fire drills to ensure that they have clear knowledge of action to be taken in the event of fire emergency. There is a service record of the Nurse Call system, fire alarm service and portable appliance tests (PAT) of all electrical appliances. We noted while reviewing the records that there were a number of accidents between January and April 2009, in some occasions there were injuries and some no injuries following the falls. Accident reports were clearly recorded and satisfactorily reviewed on each occasion however risk assessments and care Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 25 plans were not always in place. We believe that auditing accidents would enable the home to establish if there is a pattern and a reason in order to undertake appropriate risk assessment to minimise/prevent accidents. We have issued a requirement to ensure that this is in place. Staff supervision was reviewed. Evidence from the records viewed showed that staff have received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the exercise. It afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to residents’ care. The home has different ways of monitoring the quality of its services. These include, residents and relatives questionnaires, monthly medication and activities audits residents care plan reviews and daily conversation with the residents. The home has policies and procedures to include accidents, safeguarding adults from abuse and whistle blowing, complaints, confidentiality and activities. Residents’ monies were reviewed and it was noted that the amount recorded in the book corresponded with the amount found in the individual pockets in the facility provided. While we are aware that there have not been any incidents in relation to safety of residents’ monies at the home, we are concerned that the facility is not adequate and an alternative facility needs to be considered. We have made a recommendation in regards to the above and the Group Manager stated that she would facilitate the purchase of a large safe for use at Fairview Residential Care Home. All residents’ information was securely locked away. All residents have a lockable facility in the bedrooms for personal belongings. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 26 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 X 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 3 3 3 X 3 3 3 3 Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 27 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. 2. 3 Standard OP9 OP38 OP7 Regulation 13 13 15 Requirement Ensure that medication not administered is not signed for. Ensure that risk assessments are in place following a fall. All required information must be completed on admission to enable staff to meet the individual’s needs. Timescale for action 30/06/09 30/06/09 30/06/09 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 OP35 Good Practice Recommendations Ensure that a more secure facility is provided for storage of residents’ monies. Fairview DS0000034844.V375944.R01.S.doc Version 5.2 Page 28 Care Quality Commission North Eastern Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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