Inspection on 12/09/08 for Fenwick House

This inspection was carried out on 12th September 2008.

CSCI found this care home to be providing an Poor service.

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 10/08/07

Fenwick House 27/09/06

Fenwick House 30/11/05

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE Fenwick House Fenwick House 1 Cowper Road Bedford Bedfordshire MK40 2AS Lead Inspector Katrina Derbyshire Key Unannounced Inspection 12th September 2008 10:30 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.V371986.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.V371986.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 F/P 01234 350887 No email 3/7/2007 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.V371986.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. 10th August 2007 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 residential 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 people 65 years of age or over, 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 residents 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 dining room. One lounge is designated for smoking, the others are nonsmoking. There are toilet, shower and bathing facilities. The current range of fees is from £331.60 to £400.00 approx with the home accepting both private and funded placements. In addition extra charges are made for hairdressing and chiropody services and newspapers. Any charges incurred for private dentistry or ophthalmic services are the responsibility of the individual. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection was carried out on 8th July 2008. At the time of this inspection the level of provision by the home was limited and consideration, must be given on the amount of information available to assess the standards against in view of this. The home had 12 vacancies resulting in occupancy of below 65 , this level of occupancy was the same the last time we inspected the service. 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 at the home. The care of three people was looked at in detail. Tracking people’s care is the methodology we use to assess whether people who use social care services are receiving good quality care that meets their individual needs. Through discussion, observation and reading records, we track the experiences of a sample of people who use a service. During the visit the communal areas of the home were seen alongside some of the individual rooms. Time was spent with many of the people who live at the home one of the sitting areas. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. Some of the requirements that we made at the last inspection had been partially met or not met at all. No extended timescale for compliance will be given, the owner and manager must now submit to us an improvement plan that clearly shows what, how and when these improvements will be made. The focus of this inspection was to look at the key standards. What the service does well: Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 6 People living at the home said that they enjoyed the meals provided by staff. On the day of this inspection there were two options for lunch, one being fish and chips and the other egg and chips. On speaking to people they said that the ‘food tastes nice’. Menus are no longer available as the manager advised that people would forget what they had chosen, a white board in the dining room had the options for the day written on it so people would select what they wanted at the time of the meal. People also said that staff would call a Doctor if they felt unwell, they feel that this is done quickly. This means that people receive prompt medical support and can start any necessary treatment straight away. What has improved since the last inspection? What they could do better: Management and staff at the home must now change and improve in several areas including those we raised the last time we inspected the home, these include: We said the last time we visited that if there was an allegation and/or suspicion of abuse of a person living in a care home, there is local guidance that must be followed to safeguard the person. The homes own policy did not reflect the local guidance and needed to be updated, so that it was clear how a suspicion or allegation of abuse should be reported and followed through. This still had not been done. We were also informed of an alleged incident between two people living at the home two days after our visit, the manager or staff had not reported it to the safeguarding team. Any abuse must be reported so that the Commission for Social Care Inspection, the police and local authority are aware of such incidents, and a strategy is agreed to safeguard people. There is a special check by the Criminal Records Bureau that must be carried out each time a person is employed in a home this had been done. However in addition a minimum of two references that have been sent for by the manager must be secured before someone is allowed to work in the home in any capacity, this had not been carried out for the most recently employed staff member. This increases the risk of someone being employed at the home, who may not be suitable to work there. This is concerning as we raised this at the Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 7 inspection in 2006 and made a requirement, we reported in 2007 that recruitment practices then met the standards required, but at this inspection the home has reverted to not following national guidance in this area. The care documentation needs to be reviewed and improved. There was no assessment of needs for a person who had moved into the home recently. Care plans contained limited guidance, and for some people there was no plan in place for their specific individual needs. One person for example had epilepsy; there was no guidance to staff in what they should do if the person had a seizure. Attempts had been made to undertake nutritional risk assessments, but they had not been re assessed frequently. Moving and handling risk assessments were not in place for everyone, although it is acknowledged that some people do not require assistance in this area, these assessments must be undertaken to make clear the current needs of a person and monitor any change in their well being. 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.V371986.R01.S.doc Version 5.2 Page 8 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.V371986.R01.S.doc Version 5.2 Page 9 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): 1, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information on the home is sufficient to ensure people can make an informed choice as to whether to move into the home or not. Pre admission assessments are not in place for everyone so staff at the home do not have a thorough overview of each persons needs to show them the individual care and support the person will need. EVIDENCE: A copy of the statement of purpose was examined. The document provided information on the staffing, accommodation and services available at the home. People when asked were not clear if they had a copy of this, and no copies were seen in people’s individual room. People who were able to indicate stated that they had been told about the home, before they decided to move into it. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 10 We made a requirement at the last inspection that a comprehensive assessment of need is undertaken prior to a persons admission so that a decision can be taken to know if the staff at the home will be able to meet the persons needs. Two of the three files seen did contain a revised assessment; one person who had recently moved into the home did not have one. Although efforts have been made to implement an improved assessment process, it was noted that it still does not meet the national minimum standards. One example of this was the only entry next to the section ‘contact with friends’ was ‘not now!’ Therefore as assessed at the previous inspection there remains insufficient information available to enable a full picture of the persons needs. In addition there was no direct link between the persons assessment and any care plan seen, one example was a persons health needs included a diagnosis of arthritis. This had an effect on several areas of the persons life, yet no plan was in place. Intermediate care is not provided at the home. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Medication management ensures people receive their medication. However inconsistencies in care planning, assessment of risk and inconsistencies in the approach by some staff when delivering physical and emotional support place people at risk of not receiving the care that they need and can increase the risk of deterioration in their health and well being. EVIDENCE: Changes to care plans had been made in response to a requirement made at the previous inspection, however further changes and improvement are still required. There was still not a plan in place for each assessed need of each person. One person had epilepsy, and there was no plan in place to guide or direct staff in what they should do if the person had a seizure. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 12 Further documentation and assessment needs to improve. The process for assessing risk relating to moving and handling, nutrition and skin integrity needs to be consistent. One person did have a nutritional risk assessment within their care records although its original findings had never been re assessed, other people did not have one. Entries made within the daily notes included ‘pu’d x 3, to describe if someone had gone to the toilet. In addition records were kept in different places so did not provide a complete picture of the person and their needs. A book was also being kept that had a list of all the residents names, a daily recording of when they had gone to the toilet or to bed was made in this book, this practice is now seen as not appropriate and does not meet with the guidance of person centred planning. One person had stayed at the home for periods of respite care earlier in the year. A document created during one of these stays showed the person weighed 9 stone 7lb in February 2008. The person subsequently moved into the home several months later. On 06/08/08 it was recorded that the person weighed 8 stone 7lb, then on 07/09/08 it said 8 stone 4lb but it also indicated that there had been no change in the weight, which was wrong. No plan was in place to show what diet the person needed, or highlighting the loss of weight. It is acknowledged that the main loss was not sustained during their stay at the home, but that is why the assessment and subsequent plan is so important so that an obvious need such as this is identified and treated. Everyone at the home is registered with a General Practitioner. Documents viewed demonstrated that a District nurse had visited one person when they required nursing intervention. People spoken with confirmed that the staff would arrange for a Doctor to come and see them if they were unwell, they indicated that they would always do this straight away. A complaint raised to the Commission for Social Care Inspection two days after this visit, highlighted a concern that one staff member had spoken to one person living in the home in a way that did not maintain their privacy or treat them with dignity. One of the concerns raised was that the staff member had discussed the fact that the person had diarrhoea in front of all the others sitting in the room. Just before the lunch time meal one person was observed asking staff for assistance to go to the toilet. They were advised that they “were just starting toileting time” and someone would be with then shortly. Again this practice is now viewed as inappropriate, and is not person led but indicates a task orientated approach. Medication storage in the home was noted to be satisfactory as was the ordering of medicines. The recording of medication stocks and balances were sufficient so an audit of the medication systems was possible. The medication Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 13 administration records were seen to contain the signature of staff and showed that medication had been given as prescribed. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. 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 to meet peoples individual prefrences and emotional needs in this area. EVIDENCE: People spoken to stated that they enjoyed their meals. The options available for the midday meal were fish and chips or egg and chips, this was written on a white board in the dining area. When we last inspected it was noted that the menu that was on display in the front reception was very out of date by a over a year. We made a requirement that a clear system for people to be consulted on and to then choose their food options be available. We found that menus were no longer provided, just what was written on the white board. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 15 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. Also as previously assessed on speaking to people who lived in the home, they confirmed that their relatives and friends visited them. In addition one relative was spoken to they said that they visited frequently, and they were always offered a drink and no restrictions had been made to 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.V371986.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The training of management and staff is not sufficent to ensure they have a satisfactory level of understanding of the safeguarding protocols to protect the people living at the home. Systems in place for receiving, investigating and responding to complaints are inconsistent so people are not assured that their concerns will be listened to and acted upon. EVIDENCE: At the last inspection it was noted that the complaints procedure was not clear that a person could contact the Commission for Social Care Inspection at anytime if they had a concern or complaint. We made a requirement that this to be changed and that all concerns must be responded to in writing. At this visit although the manager advised that she had changed the policy, it had not been changed to incorporate what was detailed in the requirement. We were subsequently contacted, two days after our visit to the home. The person had raised concerns in July 2008 to the manager. We had examined all records of complaints and this was not detailed, neither had a written response been sent to the complainant. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 17 In addition we had made a requirement at the previous inspection because the guidance within the homes SOVA policy was not clear on the reporting procedure of an alleged or suspicion of abuse. We said it must be changed to reflect the guidance within the local policy on safeguarding adults. The current referral document used by Bedfordshire and Luton was not seen at this visit. We were then alerted two days after this visit to an alleged assault between two people living at the home, it was alleged that one person had hit another in the face. On contacting the home (this was one day after the alleged incident), no referral had been made. The Commission for Social Care Inspection then undertook the referral to the safeguarding team. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general maintenance of the environment and furnishings in the main are reasonable 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 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 Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 19 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. Some of the flooring was noted to be stained and worn in places. The flooring in a ground floor bathroom had changed to white streaks caused by water damage. Chairs in the dining area did not match. The manager did advise that it is planned to replace some of the carpeting to some of the corridors shortly. 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.V371986.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The systems for recruiting staff has reverted to a poor standard and is not sufficent to safeguard the people living at the home. EVIDENCE: The staff file of the person employed since the previous inspection was examined. It was noted to contain an application form, evidence of identification and Criminal Records Bureau checks. However the two references in place had not been sought and then secured by the manager. Both references were written prior to the person starting work at the home and both were addressed ‘to whom it may concern’. This is unsafe and does not follow the requirements in this area. It is disappointing that at the inspection in 2006, recruitment standards had been subject to a requirement. This was subsequently assessed as being met at the inspection in 2007, but the home has reverted back to unsafe practice and in turn putting people at risk. 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. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 21 Staff and records confirmed that they had attended several training courses and certificates of attendance and qualifications are available for inspection. Information seen on training included moving and handling, dementia care and fire safety training. Three people spoken with expressed their satisfaction at the care they received by the staff at the home. One person said, “they are all so nice, I don’t know what I would do without them”. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems are not sufficent to ensure an acceptable level of service ids provided for the people living at the home. EVIDENCE: As reported at previous inspections we made clear that management needed to address any shortfalls that we had noted and included this within the management section of the last two reports. This approach has not been acted upon. In light of the areas that have been detailed under various outcome groups of this report this has not been done, the management of the home must without exception address the areas for improvement detailed within this Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 23 report. The previous two inspections resulted in requirements being made and very realistic timescales for compliance were given by the Commission for Social Care Inspection to the owner and manager. These have not been met fully at this visit and concerning is for one on recruitment practice standards have reverted to being unmet. As previously assessed 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. A shared receipting system was in place for hairdressing and consideration should be given to separate receipts. 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. Examples of safety measures undertaken included: Lift serviced on 02/07/08 Gas boiler check on 20/06/08 Emergency lighting service on 04/02/08 Fire alarm service on 04/02/08. Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 24 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 3 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 3 Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 25 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. (This requirement had a timescale of 31/10/07 which has not been met in full, enforcement action is now being considered) A care plan must be in place for all assessed needs that provides sufficient guidance to staff to ensure continuity of care. (This requirement had a timescale of 31/10/07 which has not been met in full, enforcement action is now being considered) 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. (This requirement had a timescale of 30/09/07 which has not been met in full, enforcement action is DS0000063121.V371986.R01.S.doc Timescale for action 12/09/08 2. OP7 15(1) 12/09/08 3. OP8 13(4)© 12/09/08 Fenwick House Version 5.2 Page 26 4. OP8 12 & 13 5. OP10 12(4)(a) 6. OP16 22 7. OP18 13(5) 8. OP18 12 & 13 9. OP19 23(1)(a), (2)(a), now being considered) An assessment of risk for everyone relating to areas including moving and handling and skin integrity must be undertaken and reviewed at least monthly to ensure an accurate picture of a persons needs is in place. This will ensure that any changes in their well being are acted upon in a timely manner. People must always be spoken to and receive support by staff to ensure they can live their lives in a dignified manner. 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. (This requirement had a timescale of 31/10/07 which has not been met in full, enforcement action is now being considered) The homes SOVA policy must reflect the local guidance for the reporting of alleged abuse to safeguard the people living at the home. (This requirement had a timescale of 30/09/07 which has not been met in full, enforcement action is now being considered) The manager and staff must be trained in the local guidance for the safeguarding of adults and all incidences of alleged abuse must be reported in accordance with local policy to safeguard the people living at the home. A planned programme of renewal and redecoration must be DS0000063121.V371986.R01.S.doc 31/10/08 31/10/08 12/09/08 12/09/08 30/09/08 31/12/08 Page 27 Fenwick House Version 5.2 2(g) 10. OP29 7, 9, 19 Schedule 2 11. OP31 9(1), (2)(b)(i) & 12(1) sufficient to ensure people have a homely environment in which to live. A POVA First Check as a minimum must be secured alongside two references and all other matters listed in schedule 2, one reference from the most recent employer prior to commencement of employment of staff to verify their suitability to work with the people who use the service. This is to protect the people living at the home, from receiving care by someone who may not be suitable to work in a care home. Management of the home must be effective and sufficient to ensure people receive the care and support required to meet their individual needs. 30/09/08 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Consideration should be given to keeping the care records of people in individual folders. This would mean that staff have access to all the information about the person at the same time. Consideration should be given to stop using one book to record when everyone has been to the toilet or when they have gone to bed. This is not person centred. 2. OP7 Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fenwick House DS0000063121.V371986.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!