Inspection on 30/08/07 for Fen House

This inspection was carried out on 30th August 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fen House 17/08/06

Fen House 18/10/05

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Fen House 143 Lynn Road Ely Cambridgeshire CB6 1DG Lead Inspector Don Traylen Key Unannounced Inspection 30th & 31st August 2007 10:00 Fen House DS0000061337.V351991.R01.S.doc Version 5.2 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 Fen House DS0000061337.V351991.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 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. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fen House Address 143 Lynn Road Ely Cambridgeshire CB6 1DG 01353 667340 01353 653155 fh@birt.co.uk www.birt.co.uk The Disabilities Trust 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) Mrs Denise Anne O`Brien Care Home 25 Category(ies) of Physical disability (25) registration, with number of places Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2006 Brief Description of the Service: Fen House is a purpose built home for people who have suffered a brain injury. ‘Home’ is not the ideal word to describe the service because it is intended to be temporary accommodation for people who expect to be rehabilitated and not live permanently in a care home. The service started when the accommodation was opened in February 2005, in a residential area on the outskirts of Ely. The home is owned and managed by the Brain Injury Rehabilitation Trust, a division of the Disabilities Trust. The building is divided into two units. Each unit has its own front entrance from the car park at the front of the building, and the units are divided at the rear of the building by double doors across a corridor. One unit has 10 places and is for short-term rehabilitation that consists of nine single rooms and one transitional living flat. The other unit has 15 places for people who need a longer period of rehabilitation. All bedrooms and living accommodation are on the ground floor. The first floor of the home has offices, meeting rooms, and therapy rooms and staff facilities. All bedrooms are single and have an en-suite toilet, washbasin and shower. There are three dining rooms, three lounges, a games room and a smoking room as well as a main kitchen and laundry. Two of the lounges and the smoking room open onto a large enclosed central courtyard, which has been attractively landscaped in a modern style. There is a domestic style kitchen and laundry in each unit. These are used as part of service users’ rehabilitation programmes. One of the therapy rooms contains physiotherapy equipment. The staff team consists of the manager, two assistant managers, senior team leaders, rehabilitation support workers, cooks and domestic staff, as well as a team of a clinical psychologist, a consultant psychologist, a psychology assistant, two occupational therapists and a speech and language therapist and physiotherapists who are linked to the Princess of Wales hospital, Ely but are based at the service by arrangement with Cambridgeshire PCT. Continued: Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 5 People who live at Fen House are funded by their local authority or through a legal arrangement with a medico-legal representative. Fees at the time of this inspection ranged between £1,350 per week and £1,905 per week, according to assessed needs. The statement of purpose and CSCI inspection reports are available at the home in the reception area and by request at the reception office. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit started on 30th August and continued on the following day. A pre-inspection Annual Quality Assurance Assessment was completed by the home. 22 survey forms were completed by, or on behalf of people using the service and their relatives completed 7 survey forms. The responses to the surveys varied in the degree of satisfaction expressed. There were both positive and negative comments about the quality of personal care and care planning. What the service does well: The service is a valuable rehabilitation resource in Cambridgeshire for people who have suffered brain injuries. Referrals are considered from any funding PCT or authorised representative. The service has a strong medical emphasis on rehabilitation delivered through a team consisting of a manager, psychiatrists, psychologists and occupational therapists. Personal support workers provide the daily assistance and support on an individual basis. All referrals are subject to a rigorous medical assessment, including a neurological- behavioural evaluation. A written Statement of Purpose and a very informative brochure of ‘Information for Service Users and their Families’ are given to people considering moving into the home. The building and the accommodation are spacious, light and modern. There is more than adequate personal space and communal areas. There are parts of the home designed and equipped with facilities that are used specifically for rehabilitation and activities of daily living. For instance there is a ‘training’ laundry room with adjustable sinks, a dedicated kitchen, an art room, a music room and a small room used as a bank. Staff recruitment procedures and supervision are rigorous and well managed. The service is an accredited provider with the Commission on Accreditation of Rehabilitation Facilities (CARF), an organisation operating in Canada, as the only rehabilitation accrediting body available to providers in England. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 7 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. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 8 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 Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4, Quality in this outcome area is good. People who use the service or their representatives are fully assessed for their needs and informed of the care to be provided prior to moving to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the written contract was read and contained restrictions not usually seen in care homes. It was restrictive in parts to client’s’ autonomy by suggesting when they should decide to retire to bed and the expectation to participate in the rehabilitation programme in a variety of ways. Some people commented that they were not fully aware of the arrangements to place them at Fen House. Bearing in mind that some people may need an advocate, because they lack mental capacity (either temporarily or in part), this agreement to a contract may be difficult to keep. However, the service is not a permanent care home and has an emphasis on a medical model of rehabilitation and the restrictive elements are clearly stated in the contract and are risk-based decisions. One person over the age of 65 years had been admitted to the home and was provided with the complete information about the service. A specialist hospital neurological team had comprehensively assessed his needs and his medical condition was considered to be ‘stable’; a condition required by the service Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 10 prior to agreeing to any admission. The potential to respond to rehabilitation is a pre-requisite for admission. The home applied to the CSCI regarding this admission, which, because of his age, was outside of their current registration conditions. The review of registration details by the Commission will consider the need for this arrangement. Their Statement of Purpose refers to the potential need for this specialist and non-age related service and states they will consult with the Commission whenever necessary in any similar cases. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, Quality in this outcome area is good. People are provided with appropriate and individual care plans derived from their assessment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two types or approaches to care are conceived as appropriate for rehabilitation at Fen House. There are two programmes; one is for an initial twelve-week period of assessment and potential improvements in brain functioning and rehabilitation. The other programme is continuing long-term rehabilitation approach. Care plans were read for people whose plans were for a twelveweek assessment period and for one person whose plan was for him to move out of the home into his own accommodation. Initially all care plans are made for the twelve-week constant review or re-assessment. The plans included reviews to determine the clinical success of rehabilitation and whether a longer period of rehabilitation is necessary. One person stated he had been at the home a year and stated he didn’t think he would go and live elsewhere. He Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 12 was positive about the home and the support he receives and knew his plan of care and weekly activities. Care plans were very detailed with psychological input and behavioural charts that map their progress. Risk taking is a prominent aspect of the care plans that are informed by risk assessments. People living at the home also have their personal activities of daily living written for them for a week at a time. Two people showed me their schedule that they kept on their person. Another person said he kept his copy in his room. An extensive amount of time and effort had been put in by the Occupational Therapist when attempting to unravel the collapsed and lapsed financial aspects of some people’s lives. Her notes were clear and lengthy accounts of actions she had taken to determine their financial status, rights and entitlements. Some people’s financial status had to be completely re-assessed. DWP benefit entitlements and aspects beyond the responsibility of the service such as receivership or appointee had not been resolved at the stages prior to admission. Managing finances is a vital aspect of being able to function more independently and essential for achieving improvements to rehabilitation and is an issue that had not been adequately or fully addressed by some Care Managers/Social Workers involved in these cases. This matter had been neglected as an aspect of assessment and associated care planning and by default had become an issue for the service to solve. Over the past 12 months the home had discharged 35 people who moved on to other places after they had reached an improved level of independence or moved into alternative places of care more suited to their needs. Two people at the home who were preparing to move out soon spoke to me in detail about their arrangements. They were both fully involved in their care planning and were clearly in control of their lives and were confident about stating their point of view. Some people’s plans included rehabilitation into the subjects of their choice, such as being involved with animal as pets, gardens and garden centres. There were real plans to involve people in the wider community by various individually escorted trips and undertaking routine daily patterns as well as enjoying leisure pursuits. All people are registered with a local GP and have District Nurse input if necessary for needs such as epilepsy and diabetes management and advice. Weekly clinical meetings are held to discuss people on the twelve-week initial programme. For some people, a continuing rehabilitation programme is planned, should this be necessary after the twelve-week assessment period. Key workers are named qualified clinicians such as the psychologist assistant, who have responsible for people’s clinical health and wellbeing. Primary support workers have a responsibility towards aspects of personal and family contacts and ensuring the social aspects of support are provided. One relative/advocate commented there is “support for families” and there are Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 13 “planned schedules” and “staff are always available to discuss worries or concerns”. Another close relative commented, “sometimes (name) is not doing enough outside of the home”. Fen House has a large and well-equipped exercise room, or gym. However, as a centre for rehabilitation and apart from escorted walks in the surrounding land owned by Fen House there are limited resources for exercise for the grounds to be used as specific therapy, or for any outdoor interests. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, Quality in this outcome area is good. People are assured of a pleasant lifestyle whilst at Fen House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fen House has a well-equipped and spacious gym. On the afternoon of the 30th August, one person said he was going to use the gym that afternoon and showed me his weekly programme of activities that he kept in his pocket so he could refer to it whenever he wanted. He understood the programme and said it helped him to remember what he was doing. Another person informed me that it was helpful for him to have his programme of individual activities. Both people’s plans were for activities of daily living (ADL) and leisure pursuits. One person’s plan showed he worked at a garden centre and at a local charity shop. Another person is keen on gardening and is helped on a one to one basis to do this. A daily timetable of some ADL and leisure activities are written on a board indicating the activities taking place that have been arranged by Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 15 the activity co-ordinator. Trips to 10-pin bowling and the cinema are frequent. Occasional weekend visits home are facilitated by staff who act as escorts. On the first day of the inspection the in-house ‘bank’ was open for two periods of 45 minutes in the morning and afternoon. Clinical sessions managed by the psychologists and physiotherapists are held and these are a mandatory part of the rehabilitation plan. Fen house has a gym and a leisure room that is spacious and equipped with Internet access. Another room is used as an art room and there is a music room equipped with a piano and CD players and recording facilities. There is also a ‘training’ laundry room with adjustable sinks, a dedicated kitchen, and a small room used as a bank. People’s rights were upheld by the polite and respectful manner they were spoken to by support workers. Confidential matters were not spoken of in front of other people and were conducted in their own rooms. There was evidence that people are supported to rehabilitate when one person stated that she was very independent and would make sure that she got the choices she wanted. She said staff were supportive and showed respect towards her. She confirmed she was pleased with life at Fen house and she new all the details in her care plans. She confirmed that she was intending to move to an area where she has relatives and this move had already been arranged and was planned to take place soon after the inspection. She added that the care staff had supported her to achieve her choice in this matter. A relative commented that visits home are facilitated and that outings are arranged “which she loves” and “having her hair and make up done generally pampering sessions which … loves”. There was evidence of relative’s views of ways the service could improve when a close relative commented it would be “nice for more outings and things to do”. Two other relatives commented that the service can improve “in communicating with the family” and “as client’s wife I have found some difficulty in receiving information”. One person living at the home indicated to me that the choice of food could be better. Two hot meals are provided each day and diabetic needs are catered for. The food intake of one person is monitored and recorded for calorie counts and for another person for the actual frequency and amounts eaten. Kitchen staff record temperatures of cooked meats and of the fridges and freezers. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is good. People might experience a varying quality of individual support from care workers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people are registered with a local GP and have District Nurse input if necessary for needs such as epilepsy and diabetes management and advice. Two care plans included physical health needs related to diabetes, night monitoring and medication monitoring. Another person was on a measured fluid intake because of a compulsion to consume excessive amounts of fluid. Clinical sessions managed by the psychologists and physiotherapists are held and these are a mandatory part of the rehabilitation plan. One person, who self-medicates, was assisted by the District Nurse and the support workers to administer his insulin injections and record his blood sugar levels. A list of visits by the District Nurse had been recorded. Staff who administer medication are trained in safe management of medication by Cambridgeshire PCT. Medication administration records charts were read and were accurately maintained. Amounts of two controlled drugs were verified as Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 17 accurate. Controlled drugs are kept separately, stored appropriately and were recorded correctly. Observations were made of medication being administered in tablets and of an inhaler being used. Prescribed vitamin tablets were included in the MAR sheets. A daily audit of the controlled drugs was read and the MAR charts were seen to record detailed notes for PRN medication decisions. Medication waiting to be returned to the pharmacist was checked. A medication communication sheet is maintained to record and question any discrepancies noticed. The home has a satisfactory policy for the safe management of medication. Some comments were made in surveys returned to the CSCI were: “don’t have a choice the decisions are made for me”. (helped by staff) “Staff are always helpful and polite” (completed independently). Comments about support from staff included: “The staff never turn up” (independently completed) “They are too busy with…….” (completed with help) A relative was concerned that he was not kept sufficiently informed about appointments, although stated that the home “keep her fit and looking after her food to diet”. There are daily community meetings to cover the activities that each person is doing on the day. There are also monthly community meetings to discuss general affairs at the home and records of the minutes are kept. There were accounts from five people that they had been consulted about their choices for personal support and there were indications that some other people felt they had not always been consulted or adequately supported. Daily handover meetings occur every morning where cases are discussed in a brief but comprehensive manner so that their clinical and rehabilitation plan is shared by senior staff and evaluated on a daily basis. One of these sessions was observed where the emphasis was on patterns of behaviour, which are recorded in each persons ABC file (Antecedent, Behaviour, Consequence). Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is good. People are satisfactorily protected by the policies to safeguard them from abuse and generally by the staff training arrangements. However, further effort to guarantee staff competency would improve the safeguarding of vulnerable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Suitable adult protection policies and procedures are in place. According to the records most staff had been trained in adult abuse procedures. Of the four support staff who were interviewed three were not included on the staff training list and one person could not demonstrate a confident or adequate knowledge of the processes of reporting abuse, or of the immediacy to report abuse, or the likely manner in which abuse would be dealt with. This person had been recorded as being trained in adult abuse in January 2007 according to the records. The home had a notice board for people living at the home with some information pinned onto it about reporting abuse. A leaflet entitled, “Say no to Abuse” is provided for all people living at the home. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30, Quality in this outcome area is good. People enjoy a well-built and wellmaintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fen House is clean and well maintained and still appears new. It has minimal furnishings and all the rooms, corridors and communal areas are generously spacious. Fen House has a large and well-equipped exercise room, or gym, a leisure room, a music room and an art room and has supplied Internet access for those able to use this service. As a centre for rehabilitation and apart from escorted walks in the surrounding land, or when people go into Ely or other places, there are limited external resources for exercise or for specific therapies and interests to be followed. The last reports judged the environment was good. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, Quality in this outcome area is good. People are assured of reasonably trained support staff that have been recruited according to a satisfactory processes. People are not assured that all staff are systematically trained, or are assessed for their competencies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One survey form stated that there is, “a very good staff team which are making things happen for the client group”. A care professional responded to the question of how to improve the service wrote: “improve consistency of support staff, too much agency (staff) for an ABI unit”. Another person commented, “would benefit if had more knowledge of Mental Health conditions”. The service has a strong medical emphasis. The staff team consists of a manager, a psychiatrist, a psychologist and an assistant clinical psychologist, an occupational therapist, a physiotherapist and a speech and language therapist. Senior support workers or team leaders and personal support workers numbering twenty-four, provide the daily personal assistance and support on an individual basis. An activity support worker is employed. There Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 21 are two assistant managers, one of whom has the Registered Managers Award and the other is undertaking an NVQ Assessors award. The home’s training plan was read. The home has a training co-ordinator who makes the training arrangements for staff. These arrangements include Induction training; Basic Brain Injury Training (BBIT) is provided to all staff and Intermediate Brain Injury is given to more senior staff. All staff are trained in controlled physical intervention techniques (CPI) within six weeks of induction and on an annual basis; a physiotherapist provides the annual training in moving and handling and fire safety training is given from a video and is followed up by questions and answers and assessment. A method for all support staff to records and assess behaviour (BAR) is in place. It was understood by the records provided, that Cambridgeshire PCT had trained all staff in protecting vulnerable adults from abuse. All support staff are trained in Epilepsy by a dedicated training service. Cambridgeshire PCT provides medication training to named staff responsible for administering medication. The assistant manager is an NVQ assessor who monitors the administration of medication. Infection control training has been provided to all staff by video. Some of the training may need following up by monitoring and checking, in the same way for the administration of medication. For instance, one person was unsure of adult abuse procedures when asked. It is recommended that staff should receive refresher training with the Cambridgeshire PCT to ensure they completely understand how abuse must be reported and the process that follows an allegation of abuse. Three staff were undertaking NVQ level 3 awards in care and six staff had completed NVQ level 2 awards in care. The written training plan indicated that the NVQ training is “ongoing”. The organisation claim their induction programme takes place over six weeks. The first day is used to show a video about preventing abuse. Company induction follows and the basic standards relating to Skills for Care induction standards are worked through. An induction folder that is based on the skills for Care Standards is given to each new employee. During the first 5 days of induction staff do not undertake any duties. There was no evidence of the assessment of the induction learning achievements expected of new care staff, although these were indicated in the induction folders, but had not been assessed by a team leader(s) as competent or not. Four support staff were interviewed. Only one of their names appeared on the staff training records provided by the home. The reason explained was that three of them had been transferred from the organisation’s Yarmouth based service and had only recently starting work for the organisation. One person who started employment in June 2007 stated she had undergone the 5-day induction programme and named the course she had been trained in, although she had little awareness of the Common Induction Standards or Skills for Care. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 22 She stated she had received adult protection training in her last job but had not received this since working at Fen House. Another support worker who commenced employment in November 2006 had received the in-house adult protection training and the 5-day induction. Two staff files provided evidence of robust recruitment procedures and that no staff had commenced employment before a full and satisfactory CRB and POVA first disclosure had been obtained. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, Quality in this outcome area is good. People are sure of a service that is competently managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One person commented in the surveys received by CSCI that “Fen House has significantly improved in the last year since a static workforce has been in place. The manager and psychologist are giving a better direction” Another comment was, “unit is good at responding. However, head office is extremely poor”. The registered manager is completing a registered managers award. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 24 The home has maintained a record of and has sent to the Commission Regulation 26 reports and Regulation 37 notices. Various audits had been completed and included audits by the Disability Trust for a, “Stakeholders Audit” and a “User Focused Delivery Audit” on 26/02/2007. Other audits planned are for Health & Safety, Kitchens, Care Plans, Medication, Physical Wellbeing, Skill Development and Activities, Social Wellbeing and Staff Development. Further evidence of the impending audits listed in this section might help to facilitate the views of people living at the home. Fire alarms were serviced last on 15/5/2007 and are tested weekly. On 05/07/2007 staff carried out an emergency fire training evacuation. The home has a business plan for 2007-2008. The home has a comprehensive range of policies. Policies read were for, Induction, Adult Protection and Recruitment and a policy titled, ‘Management of Service User’s Money and Financial Affairs’ is being drafted in light of the findings about people’s financial status already referred to in this report under “Individual Needs and Choices”. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7 Regulation Requirement Timescale for action 15/12/07 2 YA23 15(1)(2)(c) People living at the home must be consulted for choices and for the meaningful activities and leisure pursuits they wish to follow as part of their rehabilitation care plan. 13(6) The home must ensure the safety of people living at the home by ensuring that all staff are trained in protecting vulnerable adults from abuse and that they are competent to respond in an appropriate manner should they need to deal with an allegation or suspicion of abuse. 15/01/08 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 YA2 Good Practice Recommendations Assessment information received prior to admission should include any needs associated with finances, so that a clear DS0000061337.V351991.R01.S.doc Version 5.2 Page 27 Fen House 2 YA6 3 4 YA12 YA35 plan may be made relating to these needs. More emphasis should be placed on measuring individual personal care skills and social achievement. Social functioning and daily life skills should be measured and monitored as an aspect of determining this aspect of rehabilitation and recovery. The range of meaningful activities should be increased in variety and frequency The homes Induction programme for new support staff should include evidence of an assessment of the learning and skills competency they have achieved. Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Fen House DS0000061337.V351991.R01.S.doc Version 5.2 Page 29 - 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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