Inspection on 16/02/07 for Fenn Court

This inspection was carried out on 16th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenn Court 23/06/06

Fenn Court 24/03/06

Fenn Court 31/10/05

Fenn Court 15/11/04

Fenn Court 10/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Fenn Court Broads Cottages Toothill Road Grimsby North East Lincs DN34 4ER Lead Inspector Mrs Jane Lyons Unannounced Inspection 16th February 2007 09:00 Fenn Court DS0000002914.V308346.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 Fenn Court DS0000002914.V308346.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. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fenn Court Address Broads Cottages Toothill Road Grimsby North East Lincs DN34 4ER 01472 358369 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) H4037@mencap.org.uk Royal Mencap Society Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2006 Brief Description of the Service: Fenn Court is a care home providing personal care and accommodation for adults aged 18-65 years who have a learning disability. It is part of the Mencap organisation. The home is situated in a quiet residential area in the outskirts of Grimsby and is close to local shops and amenities. The accommodation is of a domestic nature and is provided in three houses. Each house has four single bedrooms with hand basin; bathrooms to the ground and first floor; separate toilet; lounge and dining-kitchen. In front of the houses is a communal courtyard with car parking space. Each house has it’s own private rear garden. Weekly fees are: £647.40. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 1 day in February 2007. • The visit to the home lasted from 9 a.m. until 5 p.m. • Two residents spent some time chatting to the inspector. The inspector also observed staff interaction with three other residents. There were no visitors to the home during the visit. The inspector also talked to three permanent care staff, an agency care assistant, the acting manager and the team leader. Records about the care provided, and other records about the running of the home were looked at. Questionnaires about the home were sent to all the resident’s relatives, various health and social care professionals and all staff members. One staff survey and one health professional survey was returned. The inspector observed how staff and service users worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. • • • • • What the service does well: There was a relaxed and homely atmosphere in the home, residents were observed to be settled and comfortable in their surroundings. Two residents told the inspector that they were very happy living at Fenn Court. Staff spoken to were enthusiastic and liked working at the home, they were keen to ensure that residents receive high standards of care. Observation of staff support and interaction with the residents was seen to be very positive; staff displayed a very good knowledge of the individual resident’s needs, their approach was very patient, kind and supportive at all times. Staff spoken to commented on the approachability and management style of the current acting manager. All stated they found her to be friendly and efficient which has contributed to an improvement in staff moral and the day to day running of the home. The home maintains positive relations with outside agencies; surveys indicated that communication systems were good and one survey detailed “Fenn Court is a caring place; the staff treat residents as important persons with individual Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 6 and different needs which are integrated well into the community setting of the home.” What has improved since the last inspection? What they could do better: The appointment of a team leader in the home has been very positive however the acting manager requires more support in providing the appropriate management training for team leader and support with some of the day to day administration tasks to enable her to focus on completing the improvements to the care documentation, implementing the supervision programme, completing the appraisal programme and implementation of the quality assurance programme; this will better ensure the safety and welfare of the service users. Many requirements from previous inspections remain unmet and this is a cause for concern. Significant improvements to the care plans and risk assessments has been made however this work is not complete which means the home was not able to show that all aspects of health, personal and social care needs of all the service user’s are identified and planned for. Some progress has been made towards implementing a formal staff supervision and appraisal programme however this work must be completed to Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 7 provide staff with the necessary guidance, leadership and support to ensure users living in the home are safe and well cared for. Regular reviews of aspects of the homes performance through a good programme of self review and consultations, which includes the views of service users, staff, relatives and others for example care managers must be carried out. This is needed to ensure continuous improvements are made. Thermostatic valves must be fitted to the hot water taps in all three kitchen areas to protect service users from the risk of scalding. 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. Fenn Court DS0000002914.V308346.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 Fenn Court DS0000002914.V308346.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes admission process is satisfactory and although untested in recent times should provide individuals with the assurance that their needs can be met prior to coming into the home. EVIDENCE: There have been no new admissions to the home in the last twelve months, the home is fully occupied. There was evidence that all care files for service users case tracked had copies of care plans and needs assessments in place from the relevant placing authorities. Comprehensive documentation is in place to carry out assessments on potential new service users, which would guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for, although this has not yet been tested. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user needs and choices are better provided through care planning and risk assessments, however some service user documentation remains inadequate and places them at risk of not receiving the care they need. EVIDENCE: At the random inspection in October 2006 little progress had been made towards improving the care plan documentation however there was evidence at this inspection that nine of the twelve service user care plans and risk assessment documentation had been rewritten although it was disappointing to find that this work had not been completed for all the service users. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 11 Three service user files were case tracked which involved examining the care plans and other associated records, talking to staff, residents and observation during the visit. Care files case tracked had been rewritten on new formats, one service user in each of the houses was chosen for this exercise. There was evidence from discussions with the acting manager that all service users have had their needs re- assessed. Copies of the assessments were not held on file. There was evidence that the local authority have begun a programme of formal reviews for all the service users placed in the home. The new care plans are detailed and comprehensive; advice given at the previous inspection visit to ensure that the wording of the plans clearly identified the care support required and did not repeat assessment information had been taken on board. It is clear that a number of the residents have complex needs and that care plans have been developed to cover all areas of need however one case file contained fifty three care plans and advice was given to the manager to consider combining a number of the plans to make them more user- friendly for the staff. None of the new care plans had been signed by the service user or their representative however the manager confirmed that this would now be addressed through the formal reviews. Daily records had been completed by the care staff, from examination there was evidence that the some of the records were now more detailed but overall the standard remained inconsistent. Monthly evaluation records were completed, advice was given to ensure they clearly cross-referenced with the new care plans. Risk assessments for nine of the service users had been rewritten and those completed were found to be detailed and up to date. There was good evidence that the residents who display challenging behaviours had had their needs reassessed and behaviour plans had been developed. Although incidents of challenging behaviour were being recorded there was no evidence that these incidents were being monitored and evaluated on a regular basis to ensure lessons can be learnt. This is needed to ensure the welfare and safety of the service user and staff and to ensure appropriate strategies are in place. Supplementary records such as personal care records, weight charts, activity records, visits and contact with relatives, visits and contact with health care professionals were seen to be in place, up to date and maintained. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 12 A number of the files seen needed to be audited and documentation needed to be archived. Two of the service users in house three told the inspector that they had seen their new care plans but weren’t very interested in reading them. The home now has residents meetings in all the houses to enable them to influence decision making in the home. The acting manager confirmed that a number of residents had been involved in recent staff selection. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 13 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): 12,13,14, 15 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has continued to make progress to ensure individuals access more activities in the home and in the local community; this better ensures that they experience a full life. EVIDENCE: Residents are able to take part in a variety of valued and fulfilling activities, both in-house and within the community, based on individual preference. Records evidenced that service users were supported to access shopping trips, walks to the sea front, visits to local restaurants, concerts, discos and a variety of activities. One of the service users in house one told the inspector how much she had enjoyed her holiday to Skegness and another service user told Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 14 the inspector all about her forthcoming birthday party and how she had enjoyed sending out all her invitations to the residents and staff. Staff confirmed that since the staffing levels had improved and been maintained they were able to take the service users out for more trips especially at weekends. All the service users attend local authority day centres for a number of sessions; records now evidence some joint planning and recording. None of the service users were currently employed at work placements although one individual had in the past and the acting manager confirmed that support would be accessed in this area for the more able individuals. Service users residing in House One had more structured opportunities to develop social, communication and independent living skills. Staff reported service users were supported to manage shopping, cooking, cleaning and personal care. Feedback from two of the four service users confirmed this. Staff reported that they helped service users to maintain family contacts by sending cards at significant occasions such as birthdays and Christmas and supported service users on visits where this was needed. This means service users are enabled and supported to maintain family contacts. A number of service users have regular visits from their families and also make regular visits home. Service users are provided with three meals a day, staff and service users confirmed that they all contribute to the menu planning. Nutritional assessments have been carried out which were generally up to date; there was good evidence in the records of liaison with the community dietician. A number of the service users have weight gain issues and there was evidence that staff are working to provide healthy well-balanced meals. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 15 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 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare needs are well managed in an individual way, however the outstanding work on some service user care plans means some service users needs may be missed. EVIDENCE: All the service users were registered with a GP and records of visits to health care professionals were maintained, there was evidence that service users had accessed annual heath checks. Documentation seen demonstrated that service users had recently accessed support from dieticians/ diabetic nurse specialist, physiotherapists, opticians, chiropodists, orthotic consultants, psychiatrist and the clinical psychologist. Discussion with staff suggested that the new care plans provided clear guidance on how the service users health needs should be met. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 16 From the surveys sent to health care professionals three responses were received, all comments positive: one stated “There is a constant sharing of information and seeking and planning of solutions to problems; respectful patient support is given to clients in my involvement with them.” As previously detailed nine service users risk assessments have been reviewed in line with the general review of the care plan documentation. The new risk assessments were up to date and covered all areas of identified risk; associate care plans had been developed to support all areas of high and medium risk. The acting manager confirmed that no further progress had been made to develop health action plans for all the service users; advice was given to contact the local authority for support to progress this matter. The management of medication systems in the home had improved. Medication records were checked for three service users as part of the case tracking process: transcribing records were correct with the medication records corresponding to the printed label on the medication. There were no signature gaps on the records. Storage in all three homes is very limited; staff should monitor the temperatures in these areas to ensure they do not exceed the manufacturers guidelines. There was evidence of good practice with proformas developed to support p.r.n. medication for one service user; this practice should be extended for all p.r.n. medication. There was evidence that service users receiving their medication in food had letters on file from their G.P. supporting this practice; this should also be agreed with the service user’s representative and care management. Training records evidenced that progress has been made with staff completing the accredited medication course; since the last key inspection three more staff have completed the course, five staff have almost completed the course and two staff have recently enrolled. The acting manager confirmed that the homes senior management are giving consideration to the increasing age of a number of their service users who are approaching their sixties. Discussions are being held with the local authority on how to meet their future needs. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and understand how to complain if they are not happy. Staff training results in service users being protected from harm. EVIDENCE: The home has a complaints procedure in place. No complaints had been made to the commission in the last twelve months. The home had received one complaint recently, which was currently being investigated by senior management. There was evidence from examination of a number of the documents pertaining to the investigation that the procedures were thorough. The home has made significant improvements to the management of challenging behaviours in the home, however, this work has not been fully completed. The majority of staff have now accessed training in management of challenging behaviour; two staff members who were off sick on the dates arranged are having further courses scheduled. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 18 There was evidence that the small number of service users who display challenging behaviours had all had their needs reassessed and detailed behaviour management plans had been developed. Records showed incidents of challenging behaviour were being recorded. However, there was no evidence to indicate incidents were being monitored and used in such a way to ensure lessons were learnt from the handling of an incident and that future interventions were modified as appropriate. This must now happen. An issue identified at the previous key inspection in June 2006 regarding a service user’s bedroom door (in house 2) being locked during the day time had been resolved; the service user’s door now remained open. Fenn Court DS0000002914.V308346.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home which ensures their safety and comfort, however some minor improvements are required. EVIDENCE: The inspector carried out a tour of all three houses; all areas were clean and tidy. There was good evidence that redecoration and refurbishment has continued since the last inspection. The kitchen units and work surfaces in all three houses have been replaced and new flooring in the kitchens provided. The fencing had been replaced between houses one and two; door closure devices fitted to doors in houses one and three, the flooring to one of the bathrooms in house two had been replaced, new lighting, dining room furniture and photograph frames in house three. The acting manager told the inspector how much one of the service users enjoyed having his meals in the new dining Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 20 area given his previous reluctance to use the room. It was also pleasing to see that staff had obtained some old family photographs for one of the service users and had them framed and put on the wall. Recent photographs of the service users had also been framed and put on the walls; discussions with staff evidenced that they had chosen the photographs carefully only using ones that were positive images of the residents thereby promoting their dignity. There are a number of outstanding improvements required: repairs to a number of the hand basin units, a number of the radiator covers have now rusted and require repainting/ replacement and the lavatory seat in house one requires replacement. One of the service users has now been residing in house one for three years; she inherited the décor and although the carpets, curtains etc are in good condition efforts should be made by the home to ascertain if the décor is to her choice. Issues were identified with the temperature recordings of the hot water outlets in all three kitchen areas which is covered in more detail in the final section of the report. The front areas of the houses were tidy and well maintained; one of the staff had worked with the service users to plant bulbs, which had now started to shoot. The rear gardens to all three houses would benefit from new garden furniture, new planting and consideration to provide something more stimulating for the service users to observe or experience e.g. sensory area, bird table, water feature etc. The team leader confirmed that she had accessed funding for new sensory equipment for the home and she would be looking to improve the garden areas. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 21 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): 32,33,34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels in the home are sufficient to meet the service users needs however further training is needed to ensure staff have the skills to meet the needs of the service users. EVIDENCE: There was clear evidence from inspection of staff rotas and discussions with staff that the levels of care staff for each house has been satisfactorily maintained, rotas demonstrated that the needs and routines of the service users had been taken into consideration. Recruitment of new care staff for house three has been successful and this house is now fully staffed; maternity leave and staff turnover has affected the staffing in houses one and two in recent weeks but this has been covered with bank staff and the use of regular agency staff. Recruitment of new staff for house two is taking place. The inspector interviewed staff working in all three houses who all confirmed that Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 22 the staffing had improved and this enabled them to support the service users better especially with activities and trips out. Management support for the home had improved since the previous inspection; the acting manager was now back to working full time and a team leader had been appointed in October 2006.It was disappointing to see that a number of the requirements in key areas had not been fully addressed however this could probably be due to the limited hours the acting manager could work for a number of months, the lack of management experience of the new team leader and absence of administration support for the home. However at the random inspection visit in October 2006 the area manager had informed the inspector that she would continue to be based at the home to oversee compliance with outstanding requirements which clearly has not taken place. The inspector examined four staff files; three of whom had been recently employed. In general the majority of records were seen to be in place to comply with Schedule 2 of the Care Standards; one of the long term staff only had one reference in place which the acting manager confirmed she would chase up. There was evidence that staff had not been employed until POVA First checks of CRB checks were in place, records of POVA First checks were now held on file. All other documentation was seen to be in place and satisfactory. There was evidence that new staff had completed or were still working through the induction programme which meets the National Training Organisations guidelines. The acting manager has completed a full audit of staff training needs and developed a detailed programme of all the training sessions that staff require over the next six months. Significant improvements have been made with staff training and although statutory targets have not yet been met the manager has arranged courses for staff that will ensure compliance within the next few months; eight staff have accessed first aid training and further staff are scheduled to attend on the 28th February and the 1st March; staff have accessed moving/ handling training and eleven staff are scheduled to attend sessions on the 5th March and 2nd April; three staff have completed the accredited medication course with five staff near completion; eighteen staff accessed challenging behaviour training and eighteen staff accessed fire safety training in October. The manager has enrolled fifteen of the care staff on distance learning courses for health/ safety and basic food hygiene. Eight staff have completed training in risk assessment however no staff have accessed courses in care planning. Staff have accessed a number of service specific courses such as ageing in Downs Syndrome and epilepsy. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 23 The home is still trying to access support from the speech and language therapist with specific communication systems for one of the service users. The home has not yet achieved the target of having 50 of care staff qualified at level 2 NVQ; six staff have this qualification and four staff have recently enrolled on level 3 courses. The acting manager and team leader have recently enrolled on NVQ4 course in care and management. At the random inspection in October 2006 the acting manager had developed a staff supervision and appraisal programme; advice was given at the time to review the programme timescales to ensure compliance with the requirements was achieved however from case tracking the four staff files, feedback and discussion with other staff there was evidence that the staff supervision programme has not been fully implemented. A small number of staff have accessed regular sessions whilst other staff have not received any or only one session. This does not ensure that staff have the guidance and support to enable them to carry out their work correctly and place residents at risk of not having all of their needs met. The acting manager has commenced the staff appraisal programme; six staff have accessed an appraisal session. The acting manager confirmed that she had herself completed all the appraisal and supervision sessions to date; advice was given to access support from the area manager and to support and develop the team leader to carry out sessions as a priority. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 24 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): 37,38,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety of the service users is not fully ensured this has the potential to put them at risk, however, some improvements have been made in some of the administration systems. EVIDENCE: Discussions with the acting manager confirmed that she had not yet submitted her application for registration with the commission. At a meeting with the area and regional managers for the home on the 20th July 2006 the following areas of priority were identified and agreed: Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 25 • • • • • • Ensure the provision of adequate senior staff to develop and maintain the service. Review of all care documentation to ensure all service users needs are fully assessed and up to date care plans and risk assessments are in place. Develop behaviour plans to support challenging behaviour and monitoring systems to review each episode thereby informing best practice. Implement a staff training programme; all mandatory courses, general and service specific- particularly challenging behaviour and care planning. Staff to have appraisals and need regular formal supervision. Regulation 37 notifications to be provided. The acting manager has made progress towards meeting some outstanding requirements however only the final issue has been addressed in full. The following bullet point’s detail the progress made at the time of the visit. • A team leader was appointed in October however she had no management experience and therefore she has required development and support in her new role which has not provided the acting manager with the extra resources required to progress the outstanding work expediently. There is little evidence that the area manager has continued to provide support in the home to progress the outstanding requirements. Nine of the twelve service user care programmes and risk assessments have been completely reviewed. Behaviour plans for those service users who display challenging behaviours have been developed and records maintained of all incidents. A monitoring system to review each episode thereby informing best practice has not yet been implemented. Improvements have been made towards staff training; although at the time of this report statuary targets for moving/ handling and food hygiene have not been met. A number of staff have accessed risk assessment training however no staff have accessed training on writing care plans. 50 of staff have not yet accessed appraisals nor a formal supervision session. Regulation 37 notifications are now completed and forwarded to the commission. • • • • • Discussions with staff during the visit identified that staff moral was very good; they considered the manager was very approachable and supportive and dealt with issues effectively. Records evidenced that service checks had been completed for all installations and equipment. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 26 Works to ensure the integrity of the fire doors has been completed. Records to support regular fire safety checks were in place, although gaps were identified in house one. Hot water was monitored regularly and records seen during the inspection were satisfactory for bath and hand basin outlets. Records evidenced that the hot water temperature at the kitchen sink outlets regularly recorded between 50º and 60ºC; given that the service users in house one regularly support the staff with washing up and that other service users in houses two and three could turn the taps on at the kitchen sinks it is vital that thermostatic valves are provided in these areas to prevent risk of scalding. Records of hot food temperature probing and fridge/freezer temperature recording has improved in house two, gaps remained in the records for house three. The records for house three remain satisfactory. The new formal corporate quality assurance programme has not yet been implemented. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 27 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 X 2 3 3 X 4 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 3 2 2 1 X X 2 x Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 28 yes 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. Standard Regulation 1. YA6 15 Requirement Timescale for action 31/03/07 2. YA35 18 3. YA35 18 4. YA37 8 The registered person must ensure that the service user or their representative are involved and agree the individual plan of care. (Timescales of 30.01.05, 28/02/06, 28/05/06, 31/08/06 and 30/11/06 not met) NEW TIMESCALE The registered person must ensure 15/04/07 that all staff are given an annual appraisal with their line manager to review their performance against their job description and agree a career development plan. (Timescales of 31/10/04, 30/01/05, 30/06/06, 30/08/06 and 30/1/06 not met.) NEW TIMESCALE The registered person must ensure 15/04/07 that the frequency of staff supervision provides staff with recorded supervision at least six times a year (pro rata for part-time staff). (Timescales of 30/11/04, 30/01/05, 31/03/06, 31/08/06 and 30/11/07 not met). NEW TIMESCALE The registered provider must provide a 30/04/07 manager for the home who is registered as a fit person by CSCI. (Timescales of 30/10/04,30.01.05,31/03/06,15/09/06 DS0000002914.V308346.R01.S.doc Version 5.2 Page 29 Fenn Court 5. YA39 24 6. YA42 16 7. YA6 15 8. YA23 13 9. YA9 12 & 13 and 15/11/06 not met) NEW TIMESCALE The registered person must ensure that an effective quality assurance and quality monitoring systems are in place seeking the views of relatives, friends, advocates and stakeholders as well as service users. The registered person must provide an annual development plan for the home based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users (Timescale of 31/12/04,30.04.05, 30/05/06 and 31/12/06 not met.) NEW TIMESCALE The registered person must ensure that all hot food probe readings are recorded. (Timescale of 30/8/04, 30.01.05, 31/03/06, 31/07/06 and 15/10/06 not met) NEW TIMESCALE The registered person must audit all care plans for service users to check whether the information details all the service users current care needs and care provision. Where necessary care plans must be revised and updated. Timescale of 31/08/06 and 15/11/06 not met. NEW TIMESCALE The registered person must devise and implement a system in the establishment whereby the recorded episodes of challenging behaviour are reviewed in a way that supports a review of each episode with a view to informing best practice in such circumstances. Timescales of 31/08/06 and 31/10/06 not met NEW TIMESCALE The registered person must review all current risk assessments. Where necessary risk assessments must be revised and updated. The registered person must ensure they are agreed to by the service users or their representative. Timescales of DS0000002914.V308346.R01.S.doc Version 5.2 15/05/07 31/03/07 15/04/07 31/03/07 15/04/07 Fenn Court Page 30 10. YA19 18 11. YA19 13 12. YA42 13 13 14 YA34 YA42 19 13(4) 31/08/06 and 15/11/06 not met. NEW TIMESCALE The registered person must ensure staff responsible for completing service user care programme documentation and risk assessments have the necessary skills and knowledge. Where required, staff must be provided with care programme training. Timescale of 15/09/06 and 15/11/06 not met. NEW TIMESCALE The registered person must ensure health action plans are developed for each individual service user. Timescale of 31/08/06 and 15/11/06 not met. NEW TIMESCALE The registered person must ensure that the fridge and freezer temperature readings are monitored twice daily and recorded. Timescale of 31/07/06 and 15/10/06 not met. NEW TIMESCALE The registered person must ensure that all staff recruitment files contain two written references. The registered person must ensure that thermostatic valves are fitted to all hot water taps at sink outlets in all three kitchen areas. 15/05/07 15/04/07 31/03/07 31/03/07 31/03/07 Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 31 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. 2. 3. 4. 5. Refer to Standard YA19 YA24 YA32 YA33 YA35 YA33 Good Practice Recommendations The registered person should ensure copies of the home’s assessments are held in the service users current care documentation file. The registered person should audit the home against the requirements of the Disability Discrimination Act 1995, part 3. The registered person should ensure that 50 of care staff achieves NVQ 2. The registered person should provide more support for the acting manager in providing management training for the new team leader. The registered person should consider providing administration support for the home which would free up the acting manager to progress work to complete outstanding requirements. Fenn Court DS0000002914.V308346.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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