Inspection on 10/08/07 for Fenwick House

This inspection was carried out on 10th August 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 but made no statutory requirements on the home.

Other inspections for this house

Fenwick House 27/02/09

Fenwick House 12/09/08

Fenwick House 27/09/06

Fenwick House 30/11/05

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

CARE HOMES FOR OLDER PEOPLE Fenwick House Fenwick House 1 Cowper Road Bedford Bedfordshire MK40 2AS Lead Inspector Katrina Derbyshire Unannounced Inspection 10th August 2007 11:00 X10015.doc Version 1.40 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 Fenwick House DS0000063121.V343079.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 Older People. 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. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fenwick House Address Fenwick House 1 Cowper Road Bedford Bedfordshire MK40 2AS 01234 350887 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) WAGh Ltd T/A Fenwick House Mrs A Trimble Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (30) of places Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 10 beds can accommodate service users in the category of DE(E). The rooms on the top floor of the home can only accommodate service users in the category OP who have good mobility and eyesight and do not require personal care. 27th September 2006 Date of last inspection Brief Description of the Service: Fenwick House is a large detached house that has been extended and converted for use as a care home several years ago. It is located in a pleasant residential area of Bedford with convenient access to the amenities of the town. It was registered to provide care for thirty older people, 10 who may have dementia. The home has twenty eight single rooms and two that could be used for double occupancy. The bedrooms are distributed over three floors, the first floor being the only floor accessible via staircases. There are two steps up to four of the bedrooms on the first floor. The bedrooms on the second floor can only be accessed by a steep staircase. These bedrooms are not suitable for those with mobility problems and an occupational therapist has recommended that these rooms are not used by people due to the steepness of the stairs and the decreased tread depth. Three communal lounges are provided on the ground floor as well as a large lounge/dining room. One lounge is designated for smoking, the others are non-smoking. An additional table and chairs has recently been provided in the dining room to ensure that there are sufficient seats for all residents who wish to eat there, although some people choose to eat in their rooms. The following information on charges was on display in the home in August 2007. The fees for this home are £425.86 per week. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was to undertake a key inspection. This unannounced inspection was carried out on 10th August 2007. During the inspection several areas of the home were visited and the inspector spent time with some of the people who live at the home in one of the sitting areas and dining area. The care of two people was examined by looking at their records and interviewing them and staff who look after them, alongside speaking with other people that live at the home. Information from the home, through written evidence in the form of a Annual Quality Assurance Assessment has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. At the time of this visit the home had 12 vacancies. Therefore it must be taken into consideration, that the findings following this inspection are not based on a fully operational home and the effect and or differences that full occupancy may have, on the outcomes for people living there. What the service does well: What has improved since the last inspection? Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 6 We looked at some staff files to check if safety checks had been carried out before staff worked at the home. For newer staff this had been done, with references and a criminal records bureau check being in place. This means that the management at the home try to protect the people living there through vetting possible unsuitable people. 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. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People who use this service experience Adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Information gathered prior to a person’s admission to the home is not sufficient in detail to ascertain if the staff will be able to meet their needs in full. EVIDENCE: It was noted that within the care records of people living at the home, an assessment of needs was now in place following a requirement at the previous inspection. However the document mainly used a ‘tick box’ assessment, therefore insufficient information was available to enable a full picture of the persons needs. Further development is required to make sure that a comprehensive assessment of need is undertaken prior to a persons admission Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 9 so that a decision can be taken to know if the staff at the home will be able to meet the persons needs. Intermediate care is not provided at the home. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The systems for assessing risks for people in the home are not sufficient to ensure appropriate measures are in place to minimise risks relating to nutrition and falls. EVIDENCE: On examination of care files, it was noted that care plans were in place. However the guidance to staff was not sufficient to ensure continuity of care would always be given. One person regarding their personal hygiene only had the entry ‘assistance required’. The care plan documents did not at all times link directly with the persons assessment of need and a plan must be in place for each identified need. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 11 Individual risk assessments relating to nutrition and falls were not in place for all people. A brief assessment had been made relating to these areas within the document described in the previous section, this was not sufficient to show the specific risks identified for the person. One person recently admitted to the home following a fall had no assessment in place regarding this matter, and a requirement has been made. Medication records and stocks were examined. In the main the stocks and charts that were seen were noted to be correct. However the stock balance of one prescription medication was incorrect. A full audit could not be undertaken as the balances of previous medication had not been brought forward and a requirement is made relating to this matter. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to continue personal relationships and participate in social activities however a clearer system for choice relating to diet is needed to meet peoples individual prefrences. EVIDENCE: With the exception of one person, all other people spoken to stated that they enjoyed their meals. An observation of the midday meal was undertaken, people were offered fish and chips or potatoes and a pudding. The menu that was on display in the front reception however was very out of date, November 2005. A clear system is required for people to be consulted on and then choose their food options. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 13 As previously assessed staff had made arrangements for daily activities and had maintained a daily record that included activities include sing-along, board games, reminisce, crayons colouring, dominoes, and watching television. On speaking to people who lived in the home, they confirmed that their relatives and friends visited them. None of the people spoken with were aware of any restrictions on visiting and all confirmed that they could meet with their friends and family within the privacy of their own rooms. Daily records also contained entries by staff to indicate when people had received visitors. Information was also available so staff would know whom to contact if a person had a change in circumstance. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Policies relating to safeguarding adults must make clear the reporting of an alleged incident so that people are safeguarded. EVIDENCE: On examination of the complaints procedure it was noted that it was not clear that a person could contact the Commission for Social Care Inspection at anytime if they had a concern or complaint. One complaint had been recorded as being received since the previous inspection. The home needs to demonstrate how they investigate and respond to complaints, to demonstrate any changes that they have possibly made. The POVA policy of the home was also examined. The guidance within it did describe the types of abuse, however it was not clear on the reporting procedure of an alleged or suspicion of abuse. This must be changed to reflect the guidance within the local policy on safeguarding adults. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The general maintenance of the environment and furnishings in the main are good however some areas are in need of re decoration to create a pleasing and pleasant environment for all people to live in. EVIDENCE: Accommodation is provided in a large detached house that has been extended and converted for use as a care home. It is located in a residential area of Bedford with convenient access to the amenities of the town. The home has twenty eight single rooms and two that can be used for double Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 16 occupancy. The bedrooms are distributed over three floors, the first floor being the only floor accessible via staircases. There are two steps up to four of the bedrooms on the first floor. The bedrooms on the second floor can only be accessed by a steep staircase. These bedrooms are not suitable for those with mobility problems and an occupational therapist has recommended that these rooms are not used by people due to the steepness of the stairs and the decreased tread depth. Three communal lounges are provided on the ground floor as well as a large lounge/dining room. One lounge is designated for smoking, the others are non-smoking. There were no odours detected at this visit. People spoken to stated that they were satisfied with the level of cleanliness at this time. A member of the housekeeping staff was seen to be undertaking cleaning tasks at this visit, including hovering, dusting and cleaning of the bathrooms. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People feel that the staff care for them in a way that makes them feel comfortable living in the home. EVIDENCE: People spoken to at this visit felt that in the main staff would respond to them when they needed assistance. Staff rotas were also examined and showed the names of people on duty at different times throughout the day and night. Staff and records confirmed that they had attended several training courses and certificates of attendance and qualifications are available for inspection. Information submitted by the manager to the Commission for Social Care Inspection indicates that training undertaken by staff include moving and handling, dementia care and fire safety training. The homes recruitment policy and procedures as previously assessed are clear. Examination of staff files was undertaken to look at recruitment practices in the home, following a previous requirement in this area. Evidence of an application form and Criminal Records Bureau check was seen. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 18 The interaction during this visit between people living at the home and staff was supportive and respectful. People stated that they found the staff to be friendly and that this made them feel comfortable living at the home. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A system for gaining the views of people that live in the home provides an opportunity for people to influence changes in the home. EVIDENCE: As reported at the previous inspection, in the light of the areas that have been detailed under various outcome groups of this report, the management of the home has areas for improvement to fully meet the outcomes within the standards for the people living at the home. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 20 Documentary evidence was seen that showed that the home had undertaken a survey to gain the views of people living at the home and. A breakdown of responses had been undertaken and was available for inspection. Balances of small amounts of monies managed by the staff on behalf of people living at the home were checked. All balances were noted to match the amount entered onto the balance sheet. Receipts were also in place for any expenditure, examples of spending included toiletries and hairdressing. Health and safety records maintained by the home show that safety checks are carried out to ensure equipment in the home is kept in working order. Copies of the most recent inspections undertaken by the fire service and environmental health were seen and evidence was also seen that work had been undertaken in response to any recommendations made. Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement An assessment must be undertaken prior to a person’s admission to the home that is comprehensive enough to establish if the staff have the skills and experience to meet the person’s needs. A care plan must be in place for all assessed needs that provides sufficient guidance to staff to ensure continuity of care. A specific assessment regarding the nutritional needs of all people must be undertaken, to ensure the correct diet is provided and the risk of weight loss is reduced. A risk assessment relating to the risk of falls must be undertaken so that preventative measures are put in place to reduce the risk of injury to those at high risk in this area. Stock balances of medication must be recorded and brought forward to ensure a full audit can be undertaken. Timescale for action 31/10/07 2. OP7 15(1) 31/10/07 3. OP8 13(4)(c) 31/10/07 4. OP8 13(4)(b) 31/10/07 5. OP9 13(2) 30/09/07 Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 23 6. OP15 16(2)(i) Menus on display must be in date and reflect the actual choices available to the people living in the home. These must be accessible and used for them to select their meal option. A revision of the complaints procedure must be undertaken to make clear that people may contact the Commission for Social Care Inspection at anytime. All complaints must be responded to in writing so that people feel that their concerns are listened to and acted upon. The homes POVA policy must reflect the local guidance for the reporting of alleged abuse to safeguard the people living at the home. 15/11/07 7. OP16 22 31/10/07 8. OP18 13(5) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Fenwick House DS0000063121.V343079.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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