Inspection on 12/12/05 for Fearnley House

This inspection was carried out on 12th December 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fearnley House 16/05/07

Fearnley House 08/07/05

Fearnley House 17/02/05

Fearnley House 12/10/04

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Fearnley House 86 Straight Road Old Windsor Berks SL4 2RX Lead Inspector Stewart Mynott Unannounced Inspection 10:45 12 December 2005 th DS0000052919.V266941.R01.S.doc Version 5.0 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 DS0000052919.V266941.R01.S.doc Version 5.0 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 Adults 18-65. 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. DS0000052919.V266941.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fearnley House Address 86 Straight Road Old Windsor Berks SL4 2RX 01753 863752 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) Choice Limited Mrs Dionne Catherine McGlinchey Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000052919.V266941.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th July 2005 Brief Description of the Service: The home is owned and run by CHOICE Ltd and provides care for people with multiple needs. This is a new home that opened a little over 18 months ago, to provide care for four young residents with learning and physical disabilities. The home is in a bungalow on a main road, with shops nearby. The house is set in a medium size garden with a tarmac car park in the front. The rear is a grassed area with an annexe for an office. There is a summerhouse for use as an educational facility. The house comprises a spacious L-shaped lounge and dining room and kitchen, with four bedrooms and bathrooms and toilets. DS0000052919.V266941.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection occurring during the day lasting for 3½ hours. The deputy manager who was on duty facilitated the inspection. Time was spent reviewing the management and staffing at the home and records relating to this to evidence these systems at the home. After this the remainder of the inspection was spent in the lounge observing the daily life and lifestyle, which included lunch with staff and service users. Service users have limited verbal skills therefore views were gained indirectly through observation and staff support. This was a positive 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. DS0000052919.V266941.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000052919.V266941.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has a comprehensive policy and procedure for referral, transition and admission for new service users. EVIDENCE: The deputy manager confirmed that the service users within the home have been resident since the home was first registered. There is a detailed admission policy and procedure within the home and the statement of purpose. DS0000052919.V266941.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 to 10 were not assessed during this inspection. EVIDENCE: DS0000052919.V266941.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Service users participate in a wide range of appropriate activities both within the home and in the local community. Service users have a flexible daily routine supported by a friendly and respectful staff team who utilize good communication methods. There is an appropriate diet offered and service users are given choice at mealtimes of how and where they wish to eat their meals. EVIDENCE: The deputy manager discussed the arrangements for service users access to activities. Staff support two service user using their communication boards in the lounge each day so they are fully aware of what activities have been organised. Each service user has an individual schedule of weekly events and the support worker confirmed that these are individualised to each service user. The activity program is very varied both in the local community and in house. Activities include using local colleges, leisure centres, outdoor activities and more specialist centres. In house, two service users have aromatherapy and reflexology sessions and all service users enjoy a weekly music therapy session, which was in progress during the inspection. Activities are reviewed regularly and during service users review as evidenced in recent records. DS0000052919.V266941.R01.S.doc Version 5.0 Page 10 Time was spent with service users over the lunch time period. Both staff on duty demonstrated a good awareness of each individual’s support needs and were respectful and friendly providing support for service users with their daily routines. Communication cards and boards were used to aid the support provided. Lunchtime was relaxed and service users enjoyed their meal. One service user prefers to sit at the breakfast bar in the kitchen to eat their meals. Cards are used by the staff with the service user to sequence the events during the meal. The three other service users were supported and offered as much choice and independence as possible. One service user requires pureed meals and staff assistance to eat, which was provided in a sensitive manner. The menus are varied over a three-week cycle with the main meal being prepared and provided during the evening by the cook, who is experienced and has worked at the home for some time. DS0000052919.V266941.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 to 21 were not assessed during this inspection. EVIDENCE: DS0000052919.V266941.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were not inspected during this inspection. EVIDENCE: DS0000052919.V266941.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 to 30 were not assessed during this inspection. EVIDENCE: DS0000052919.V266941.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 35 A competent and effective team that have received an appropriate range of training support service users. It was not clear from the records examined that new staff recruited after July 2004 have had a POVA first check completed before commencing employment whist awaiting their full disclosure. EVIDENCE: The rotas for the last 4 weeks were examined to assess the staffing levels within the home. During the day there are two members of staff with the addition of the registered manager during the week. There is one support worker plus a staff member sleeping in during the night. The staffing levels in the home are stable. The deputy manager confirmed that there is a varied training program to provide statutory training and more specialist courses to meet the needs of the current service users. This was evidenced in both a training overview for the staff team and individual training profiles for staff that demonstrated that staff have attended most training. Two more recently recruited staff have already undertaken a good range of training. The deputy manager confirmed that the senior team support staff inductions using the Provider’s format. Evidence of induction recording for a new member of staff was seen. New staff have progressed through the LDAF and both the registered manager and deputy are mentors. The support worker on duty DS0000052919.V266941.R01.S.doc Version 5.0 Page 15 confirmed that they had received a good supportive induction and had attended a good variety of courses. The staff members training file indicated this. The staff member clearly had a good understanding of service users needs. The recruitment procedures were discussed with the deputy manager who described a coordinated approach with the head office personnel officer. Staff are interviewed and selected in the home by the registered manager and deputy. Pre employment checks are collated and checked by the personnel officer. Two staff member’s files were examined and were organised to provide a completed application form, health declaration, references and identification. Copies of CRB’s are also held with in the home at present. It was not clear from these records that new staff recruited after July 2004 have had a POVA first check completed before commencing employment whist awaiting receipt of a full disclosure. The deputy manager was advised that evidence that staff had been checked against the POVA register before commencing employment must be maintained in the home. Acceptable evidence is either a POVA first check or enhanced CRB disclosure or alternatively confirmation that these have been completed, if these records are not to be stored at the home. DS0000052919.V266941.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home is managed by a competent registered manager and service users benefit from a well run home. There are effective systems to monitor the quality of the service provided within the home. The Provider actively seeks service users and relatives views. There are clear systems and records maintained that evidence that the health, safety and welfare of service users are protected. It is a recommendation that the fire risk assessments are reviewed to ensure they are up to date as it was unclear when this was last undertaken. EVIDENCE: The registered manager has been in post since the home opened and is experienced and suitably qualified. Staffs spoken to were complementary about the manager’s approach to the overall management of the home and support to both the staff team and service users. The home has good systems to monitor the quality of the service provided. The provider has recently sent out questionnaires to service users and their representatives to gain their views. This information is collated and the deputy DS0000052919.V266941.R01.S.doc Version 5.0 Page 17 manager confirmed that this information would be shared and acted upon. The provider representative undertakes regulation 26 visits that are unannounced on a monthly basis. The scope of these visits is thorough and the subsequent reports are of a very high quality. This clearly demonstrates a commitment to the monitoring of the quality and operating systems within the home. The deputy manager explained the homes arrangements currently in place for the protection of service users and staff health, safety and welfare. The deputy manager demonstrated a sound understanding of the homes responsibilities in this area. The homes records were sampled to evidence this to include fire safety records, water temperature monitoring, serving temperatures for food, electrical testing records, COSHH assessments and general risk assessments. These records were very well organised into a “health & safety” and “fire records” folder. All information viewed was relevant and completed appropriately in line with legislation and the homes own procedures. It is a recommendation that the fire risk assessments are reviewed to ensure they are up to date as it was unclear when this was last undertaken. The Provider uses an external company to audit the health & safety procedures within the home on an annual basis. The records for this year were viewed and highlighted no issues with the homes procedures and records keeping. The procedure for recording accidents was viewed and records relating to these were appropriately stored. The last two accidents for services users were case tracked and records had been made within service users care files. DS0000052919.V266941.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000052919.V266941.R01.S.doc Version 5.0 Page 19 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 YA34 Regulation 19 Requirement That the registered manager keeps a record in the home to evidence that new staff have been checked against the POVA register before commencing employment. Timescale for action 31/01/06 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 YA42 Good Practice Recommendations That the registered manager reviews the fire risk assessments at the home to ensure they are current and reflective, as it is unclear of when they were last reviewed. DS0000052919.V266941.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000052919.V266941.R01.S.doc Version 5.0 Page 21 - 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. 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