Inspection on 31/10/05 for Fenn Court

This inspection was carried out on 31st October 2005.

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 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenn Court 16/02/07

Fenn Court 23/06/06

Fenn Court 24/03/06

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 Kishon Dee Unannounced Inspection 31st October 2005 09:30 Fenn Court DS0000002914.V268968.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 Fenn Court DS0000002914.V268968.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. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 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) Royal Mencap (Housing & Support Services) Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 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. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an un announced inspection and was carried out with the team leader, service users of Fenn Court and members of staff on duty. The inspection took seven hours to complete and included discussion with service users and staff, a tour of the premises and an examination of files and records relating to the service. There have been no additional visits carried out since the last inspection. Five of the current service users were spoken to and four members of staff on duty. Their comments are included in this report. What the service does well: What has improved since the last inspection? What they could do better: Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 6 Over the last months the home has been managed by an a team leader and although there have been limited minor improvements it has lacked the focus and direction of a manager. At the present time staff are struggling to provide a level of care which meets service users physical and emotional needs and a registered manager needs to be recruited as a matter of urgency. As a result of a lack of leadership all aspects of the home require work, the environment, the paperwork and the staffing levels and support of them. Many requirements from previous inspections remain unmet and this is a cause for concern. An appropriate budget must be provided for the outstanding environment. work to the If the home are looking at residents paying for work to the home or their room this must be discussed with their next of kin. Work that has been paid for by residents must be re-imbursed. 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. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 7 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.V268968.R01.S.doc Version 5.0 Page 8 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): 1&2 &5 The homes admission process is inadequate and does not provide individuals with the assurance that their needs can be met prior to the coming into the home. EVIDENCE: The home has a service user guide but this does not contain all of the information required and it is not in a format which is accessible to all current and future residents. Each resident has their own individual file and a number of files were looked at. Two residents admitted to the home did not have a care management assessment and care plan. A letter had been sent to the care management team to request copies of the assessment but this was a member of months and had not been followed up. The admission procedure is not adequate to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. This does not give potential residents the assurance that the home is able to meet their needs. Three individual care files were examined 2 of these contained a copy of a statement of main terms and conditions and a licence agreement. These documents do not contain all of the required information. The documents had been signed by the service manager on behalf of Mencap but none had been signed by the residents. This situation for each of the above points was also noted at the last inspection visit when a requirement was made for action to be taken to ensure that Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 9 proper assessments were carried out before prospective residents entered the home and that statements of terms and conditions were adequate and signed. There was no evidence that this action had been taken. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7&8&9 Limited progress has been made to the way in which staff record, review and risk assess the care needs and expectations of the residents. Individuals are not involved in the running of the home. EVIDENCE: Individual care plans are in place for all residents and which set out the health, personal and social care needs identified for each person. All of the plans looked at have not been evaluated on a monthly basis. Any changes that are made to the care being given is documented and implemented by the management. Two members of staff said that they are not currently given the opportunity to contribute to the development or the reviewing of the care plan although they would like to assist. Discussion with staff suggested that some needs were being addressed even though there was a lack of clear guidance in the plans. This approach is dependent on staff memory and good verbal communication systems. Residents are at risk of not having their health care needs met if these informal systems break down. This situation was also noted at the last inspection visit when a requirement was made for action to be taken to meet the shortfall. The home must take action to meet this requirement. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 11 In one house a new bathroom was been fitted. During discussion with the team leader it transpired that one resident had been invoiced for the bathroom suite, shower and the fitting costs and another was going to be invoiced for cost of the tiling. The cost of the bathroom, shower and fitting was just under two thousand five hundred pounds and there was no evidence that the next of kin had been asked about meeting this cost. The file was examined and an occupational therapy assessment had been completed recently which said that the resident required a bath seat and a grab rail. This must not happen and the home must meet the cost of this work. One resident said that ‘the staff are good, they help me with my care and support me with my activities. Staff enable residents to take responsible risks in their daily lives, one resident discussed how she is now working towards travelling independently on the bus following a risk assessment being completed and the information put into the care plan. This is a personal goal for the resident and is improving her independence. The resident has a good understanding of his/her personal limitations and abilities and recognises when assistance from staff is needed. Not all risks assessments looked at where up to date or been reviewed and this has the potential to place residents at risk. The home does not have residents or relatives meetings to enable them to influence decision making in the home. The team leader said that at this time service user are not involved in staff selection. This situation was also noted at the last inspection visit when a requirement was made for action to be taken to meet the shortfall. The home must take action to meet this requirement. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 12 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): 11 & 12 & 13 & 17 Residents are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for, staffing levels do at times restrict access to activities. EVIDENCE: Residents are able to take part in a variety of valued and fulfilling activities, both in-house and within the community. One individual reported that she had been to her keep fit class that morning and a number of residents where preparing to go to a Halloween party that evening. The staffing levels within the houses do impact on the number and amount of activities that can be offered, this is particularly a problem on a weekend. There is often only one member of staff on duty on a weekend and this means that no resident can go out or do activities outside the home. Inspection of one residents file suggests that her behaviour deteriorates on a weekend and staff feel this is due to boredom. Residents spoken to are happy with the way that staff look after them, they felt that they are given choices in their everyday life and staff respected their privacy and dignity. Observations of the interaction between staff and Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 13 residents showed that there is a good relationship between the two groups of people based on trust and friendship. A number of people living at the home were spoken to and everyone who commented on the food said how good it was. Menus seen offer the residents a balanced and varied diet, with meal times being flexible enough to accommodate individual preferences and give staff time to assist those who need help with feeding and drinking. Two residents said that they sit down as a group on a weekly basis and plan the menus for the following week. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 14 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): 18 & 19 & 20 Not all met. service user’s health, personal and social care needs are being fully EVIDENCE: Information, within the care plans looked at, shows that each resident has their own preferred daily routine including their choices and wishes regarding health, personal and social care. As stated earlier these are not reviewed on a monthly basis. Discussion with the staff indicated that they have a good knowledge and understanding of the care needs of each individual and how they like this care to be given. The care and support is given in a way which promotes the residents dignity, privacy and independence. Two residents said that they chose what time they get up and go to bed and that staff offer care and support to residents when and how they choose. All staff are currently completing accredited medication training. The medication cupboards in two of the houses had the keys in them and were unattended by staff, The medication records were checked against the medication held in one of the houses and was generally well completed and accurate. A couple of signatures were found to be missing. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 15 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): 22 & 23 The home has an adequate complaints system with some evidence that residents feel that their views are listened to and acted upon. Adult protection procedures and practices must improve to ensure residents are protected from abuse. EVIDENCE: The complaints procedure had also been produced as a simple flow chart with pictures accompanying the written text. It has also being produced onto audio tapes for residents. A record of complaints was kept at the home. There had been no complaints since the previous inspection. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 16 Two service users interviewed in house 3 said they would tell the team leader if they were not happy and she would look into this. The policies and procedures for the protection of vulnerable adults needs to be reviewed to ensure it links into with the multi agency guidelines. This was a requirement of the last inspection and there was no evidence that action has been taken to meet this. As stated earlier one resident had been invoiced for the cost of installing a new bathroom suite and another for the tiling in the bathroom with no consultation with their next of kin. The home must re-imburse the individuals for the cost of this work. Three residents have also paid for fitted wardrobes in their bedroom. The team leader said that one next of kin had been involved in this but no one had been contacted regarding the other two rooms. This practice is questionable as if the residents left the home they could not take this furniture with them. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 17 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): 24 & 25 & 26 & 28 & 30 The environment does not provide service users with surroundings in which to live. safe and comfortable EVIDENCE: The home comprised of three houses and was situated in a quiet cul-de-sac in a residential area of Grimsby. It was in keeping with the local area and close to local shop, pub and bus service. Room sizes were given in the home’s statement of purpose. On the whole the environment was clean and comfortable with domestic fittings and furniture. A tour of the premises had showed that the home was generally in good repair but some areas required attention, this was the case at the last two inspections and these areas remain outstanding. The home must take action to meet these outstanding shortfalls. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 18 In house 1 the settees and chairs in the lounge were badly stained and the fabric looked worn from having been frequently cleaned. The cushions have also become worn and are now lumpy and un-comfortable to sit on. The team leader has had a company in who has said that these cannot be successfully cleaned and they need replacing. Matching throws had been put over the settees and chairs to cover the marks. The TV in the main lounge is not working and requires repair or replacement. In house 2, Some areas require re-painting, particularly two residents bedrooms. The settees and chairs in the lounge were badly marked and require replacement; again matching throws had been used. The lounge has been redecorated, this requires finishing off such as pictures hanging on the walls. The hall, staircase and landing walls were marked, stained and had areas where paint had come off; these required repainting. The call system was covered up with paper in one residents bedroom and the team leader was asked to remove this. In House 3 The letter box is missing and requires replacing, the work tops in the kitchen require replacing, the laminate surface in parts of the work surface has perished. The carpet needed shampooing in one residents room and the furniture required replacement. A planned maintenance and renewal programme for the fabric and decoration was not available. The registered person must provide this. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 19 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): 33 & 35 & 36 The deployment and number of staff is not sufficient to meet the needs of the residents and carry out activities. Limited progress has been made in the training and supervision of staff and this could place residents at risk. EVIDENCE: The Mencap service review of Fenn Court had identified staffing levels as an issue. The review identified that the home was at least 54 hours per week short of care staff. From looking at records and speaking to staff it became evident that there are times when staff are unable to undertake activities with the residents due to the staffing levels. This is particularly an issue at the weekends when residents are not going to centres and classes. A requirement for the registered person to review staffing levels was ongoing from the last two inspections. There is no evidence that this has been done and the home must take action to ensure that this requirement is met. Three staff files were looked at and this demonstrated that staff have not been receiving supervision on a regular basis. One member of staff has worked at the home for nine months and only just received supervision for the first time. 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 team leader said that the home was aware of this shortfall and all staff had recently had a supervision session, the supervision records had not been placed into staff files. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 20 The inspector observed during the inspection that staff acted in a respectful manner to service users and communicated appropriately. The manager of another service who is working at Fenn Court two days a week has recently done an audit of the staff training and this has identified that a number of staff require mandatory training courses. She is currently identifying courses to meet this shortfall. As identified at the last two inspections the registered person must ensure that staff complete and are kept up-to-date with mandatory training. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 21 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 & 40 & 42 & 43 The home is not being managed properly and there is no leadership, guidance and direction to staff to ensure residents receive consistent quality care. This results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The home’s manager had applied to the CSCI for registration and this was refused. This has resulted in the person now acting as team leader. A manager from another home is acting as manager two days a week but this has only recently commenced. While residents, their visitors and staff made positive comments about the staff team, some examples were given of poor communication, staff being unclear about what is expected of them and practice being inconsistent between shifts. Paperwork both for residents, staff and the homes policies and procedures require work. Fenn Court has had a service review and part of this covers the Quality Assurance process this is not sufficient to cover all of the areas required and this must be done. The home does not always have a first aider on duty. A form has being developed to record fridge, freezer and meat temperatures but Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 22 this is not been completed regularly. The fire risk assessment was last reviewed in March 2003 and has not been reviewed. These were requirements of the previous inspection and action must be taken to meet this shortfall. Many of the requirements from previous inspections remain outstanding and have being so for some time. These requirements are across the entire running and management of the home. The home must ensure that the home is properly managed if they are to avoid improvement notices being issued. Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 23 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 2 2 X X 2 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 X 2 X 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fenn Court Score 2 X 1 X Standard No 37 38 39 40 41 42 43 Score 1 X 2 2 X 1 3 DS0000002914.V268968.R01.S.doc Version 5.0 Page 24 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. 1 Standard YA1 Regulation 5 Timescale for action The registered person must 10/02/06 provide a service user guide which covers the information required by 1.2 of this standard and regulation 5 of the Care Home Regulations for adults 1865 and produce it in a format accessible to service users. (Timescale of 30/10/04 new timescale of 30.01.05 also not met NEW TIMESCALE ) The registered person must 31/03/06 obtain a copy of the care management assessment and care plan for all service users. (Timescale of 30/9/04 not met and new timescale of 30.01.05 also not met. NEW TIMESCALE ) The registered person must 31/03/06 update the statement of terms and conditions to ensure it includes all information required by standard 5.2 standard including the room to be occupied and fees charged, and reflects local practice in respect of holiday provision. The contract must be issued to all service users on admission. (Timescale of 30.01.05 not met. NEW DS0000002914.V268968.R01.S.doc Version 5.0 Page 25 Requirement 2 YA2 14 3 YA5 5 Fenn Court TIMESCALE) 4 YA6YA18 15 The registered person must 28/02/06 ensure that the service user or their representative are involved and agree the individual plan of care. This must be updated in light of changing needs ands must be reviewed at least monthly.( Timescale of 30.01.05 not met. NEW TIMESCALE) The registered person must ensure that service users are offered opportunities to be involved in the day to day running of the home and contribute to the development and review of policies and procedures. (Timescale of 30/9/04 not met and new timescale of 30.01.05 not met NEW TIMESCALE ) The registered person must ensure that all risks assessments are completed and monitored and reviewed at least monthly. The registered person must ensure that the medication is kept locked at all times. Medication records must be accurate and well completed. The registered person must ensure that all staff members involved with medication receive accredited training. (Timescale of 30.09.04 not met and new timescale of 30.01.05 not met. NEW TIMESCALE ) The registered person must ensure that the Mencap corporate policy/procedures for the Protection of vulnerable adults is reviewed and amended to ensure it links with the multi agency guidelines in respect of alerting, referral and investigation. ( Timescale of DS0000002914.V268968.R01.S.doc 5 YA8 12 31/03/06 6 YA9 13 28/02/06 7 YA20 13 14/02/06 8 YA20 18 31/03/06 9 YA23 13 31/03/06 Fenn Court Version 5.0 Page 26 10 YA23 13 11 YA24 23 12 YA26 23 13 YA12YA33 18 14 YA35 18 30.01.05 not met NEW TIMESCALE ) The registered person must ensure that the finances of people living at the home are protected. Residents who have been charged for work to the home must be re-imnbursed. The registered person must ensure that the work specified is carried out. A programme of routine maintenance and renewal must be developed. )Timescale of 31.08.04 and new timescale of 30.04.05 not met NEW TIMESCALE ) The registered person must provide in bedrooms all the items required by 26.2 of this standard or document in service users’ individual care plans where risk assessments or service user preferences indicate these should not be provided. (Timescale of 31/8/04 not metand new timescale of 30.01.05 not met NEW TIMESCALE ) The registered person must ensure that staffing levels are sufficient to meet the need of the current service users. The registered person must provide a training and development plan for the home that includes all mandatory training, service specific and NVQ and is prepared using information gathered from the staff annual appraisals. The registered person must ensure that new employees receive induction training within six weeks of appointment and foundation training within 6 months of appointment. The registered person must ensure that all staff complete and are DS0000002914.V268968.R01.S.doc 28/02/06 31/03/06 31/03/06 28/02/06 31/03/06 Fenn Court Version 5.0 Page 27 15 YA35 18 16 YA35 18 17 YA37 8 18 YA39 24 up-to-date with mandatory training. ( Timescale of 30.01.05 not met NEW TIMESCALE ) The registered person must 30/01/05 ensure 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. (Timescale of 31/10/04 not met new timescale of 30.01.05 not met NEW TIMESCALE The registered person must 31/03/06 ensure that the frequency of staff supervision provides staff with recorded supervision at least six times a year (pro rata for part-time staff). (Timescale of 30/11/04 not met and new timescale of 30.01.05 not met NEW TIMESCALE ) The registered provider must 31/03/06 provide a manager for the home who is registered as a fit person by CSCI. (Timescale of 30/10/04 not met and new timescale of 30.01.05 not met NEW TIMESCALE ) 30/05/06 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 planningaction-review, reflecting aims and outcomes for service users (Timescale of 31/12/04 not met and new timescale of 30.04.05 NEW TIMESCALE ) The registered person must 31/05/06 ensure that service users have DS0000002914.V268968.R01.S.doc Version 5.0 Page 28 19 YA40 12, 22 Fenn Court access to relevant policies produced in an appropriate format. (Timescale of 31/11/04 not met and new timescale of 30.04.05 not met NEW TIMESCALE ) 20 YA42 13 The registered person must 31/03/06 provide the displayed procedure to follow in the event of a fire in a format more accessible to service users. The registered person must ensure that the corporate policies and procedures are reviewed and amended to ensure they meet recent legislation and best practice guidance. (Timescale of 30/9/04 mot met and new timescale of 30.06.05 not met NEW TIMESCALE ) The registered person must provide a suitably qualified nominated first aider at all times. (Timescale of 31/11/04 not met and new timescale of 30.01.05 not met NEW TIMESCALE ) The registered person must ensure that hot food probe readings are recorded. (Timescale of 30/8/04 not met and new timescale of 30.01.05 not met NEW TIMESCALE ) The homes fire risk assessment was last reviewed in March 2003 and must be reviewed at least yearly. Timescale of 30.01.05 not met NEW TIMESCALE The registered person must review the budget and make available enough funds to ensure that all the requirements relating to the environment at Fenn Court can be attended to as matter of urgency. Timescale of 30/4/05 not met NEW TIMESCALE DS0000002914.V268968.R01.S.doc 21 YA42 13 31/03/06 22 YA42 16 31/03/06 23 YA42 23 28/02/06 24 YA42 23 31/03/06 Fenn Court Version 5.0 Page 29 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 YA6 Good Practice Recommendations The registered person should identify on care plans and risk assessments in service users individual plan the person who has written it; date implemented and date reviewed (if applicable). The registered person should consider how an option of a seven-day annual holiday could be offered to service users within the basic contract price. The registered person should ensure that the relatives of service users are aware of the home’s complaints policy. 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 will have achieved NVQ 2 by 1st April 2005. 2 3 4 5 YA14 YA22 YA24 YA32 Fenn Court DS0000002914.V268968.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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