Inspection on 27/09/06 for Fenwick House

This inspection was carried out on 27th September 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fenwick House 27/02/09

Fenwick House 12/09/08

Fenwick House 10/08/07

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 Mr Pursotamraj Hirekar Unannounced Inspection 27th September 2006 03:00 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.V311711.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.V311711.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.V311711.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. 30th November 2005 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 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 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 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 residents choose to eat in their rooms. There are sufficient toilet, shower and bathing facilities. The fee was around £425/-. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out by pursotamraj hirekar on 27/09/06 over 3 hours. The senior care assistant had coordinated the entire inspection. The methodology of the inspection included study of relevant care documents, discussion with the staffs and service users’ partial home visit was undertaken; observations were made of staffs and service users’ interaction. What the service does well: What has improved since the last inspection? What they could do better: The home must undertake pre-admission assessment of all new admissions and use the outcomes for preparation of the care plans. The home must ensure that the administartion of medication records were regularly updated. The home must undertake nutritional assessment of all the service users’ and implement the menus specific to individual service user’s dietary needs. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 6 The home must undertake an audit of the premises with the help of OT and EHO in relation to the category of service users’ living in the home and implement the recommendations made in their reports. The home must ensure statutory checks prior to the appointments of the staffs’. The home’s complaints policy and procedure must ensure in practice that the service users’ needs and aspiration were protected. The home must ensure to undertake pre-admission assessment, update medication records, carry out nutritional assessment, undertake OT and EHO audit, have robust statutory staffs checks and deploy at least one senior staff person around the clock to ensure the aspirations, needs and quality of life of the service users’ were promoted. 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. Fenwick House DS0000063121.V311711.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.V311711.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made arrangements to provide information that enabled the potential service users’ family to make informed deccision. However, The home must undertake preadmission assessment of all new admissions and use the outcomes for preparation of the care plans. EVIDENCE: The home had made arrangements to provide documentation such as statement of purpose, service users’ guide, home brochure and trial visits that would inform the potential service users’ representatives to make an informed decision regarding choice of the home. On the day of this inspection a couple had come to visit the home to find out whether the home would be suitable for their parent. On asking they have said that they are considering admission of their parent at the home. On the 14/10/06 a visit was undertaken by a visitor to find out the suitability of the home for her sister and found that the environment was of poor quality and decided not to admit her sister in the home. This information was passed on to the commission by the social services on the 16/10/06. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 9 The home had 2 new admissions dated 04/09/06 and 09/09/06 for respite care. However, their pre-admission assessments were not made available on this inspection. 1 service user’s care plan was prepared on the 06/09/06 and was scheduled for a review on the 06/10/06. It was not clear during this inspection on what basis the care plan was prepared without undertaking preadmission assessment. The home must undertake pre-admission assessment of all new admissions and use the outcomes for preparation of the care plans. Fenwick House DS0000063121.V311711.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made arrangements for the monthly review of the care plans of service users’ and were regularly updated. However, the administartion of medication records needed regular update. EVIDENCE: The home had made arrangements for the monthly review of the care plans of service users’. On this inspection 5 service users’ care plan monthly reviews were seen. Service user –1 monthly care plan was reviewed on 12/08/06 and the service user had moved to another home on 27/09/06 for convenience of the family members visit and health reasons. Service user – 2 monthly care plan review was undertaken on the 24/08/06 and the next was scheduled for 23/10/06. Service user – 3 monthly care plan review was undertaken on 03/09/06 the next one was scheduled for 3/10/6. The care plan summary was presented in 2 different tools; the staff member available on the inspection did not give the reasons for the same. Service user – 4 monthly care plan review was Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 11 undertaken on 22/9/6 and the next one was scheduled for 22/10/6. Service user – 5 monthly care plan review was undertaken on the 06/09/06 and the next one was scheduled for 06/10/06 there was no clarity in the care plan review document with regard to the managers comments or action taken on the outcomes of the review. Pharmaceutical advice checklist dated 18/07/05 action plan identified 5 problems; there was no evidence provided on this inspection to show whether the problems resolved. The staff member available on this inspection was not aware of this issue. The home had medication policy and procedures in place. However, in practice there were concerns with regard to the administration of medication and the records thereof; medication mars sheet of service user –1 had no start date and the prescription were not made available on inspection. Service user –2 had no start date and prescription was not made available. Service user –3 mars sheet had the start date information recorded but the prescription was not made available on this inspection. Service user – 4 mars sheet had recorded starts date information and also had provided the medication prescription. The medicine was stored in a safe and secured place. The list of staff those who are competent to administer medication must be kept up-todate. Fenwick House DS0000063121.V311711.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users’ were engaged in appropriate activities. The home must undertake nutritional assessment of all the service users’ and implement the menus specific to individual service user’s dietary needs. EVIDENCE: The home had made arrangements for the service users’ daily activities and had maintained a daily record that included activities include sing-along, board games, reminisce, crayons colouring, dominoes, and watching television. The home also had made arrangements for the family members and the representatives of the service users visit and interact at their convenience. There was no evidence provided on this inspection with regard the individual service users’ nutritional assessment and a balanced diet that correspond to the nutritional assessment. The home must undertake nutritional assessment of all service users’ and develop food menu that was specific to individual service users nutritional needs. Further, the implementation of the balanced diet needs to be monitored regularly in conjunction with the health of all the service users’. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s complaints policy and procedure must ensure in practice that the service users’ needs and aspiration were protected. EVIDENCE: On this inspection during the discussions with service users’ 1 service user said that ‘I am fine, but cannot get whatever I want and I do not want to ask anything, because I know that it will be ignored, and I do not want to feel let down after asking’. These evidence that the risk assessments and needs assessments of the service user were not comprehensive and were not dovetailed into the care plan for implementation. The home must undertake robust risk assessments, needs assessments of all service users’, incorporate the outcomes into the care plans to implement them and monitor the quality of service delivery and quality of life of service users. On the 14/10/06 a visit was undertaken by a visitor to find out the suitability of the home for her sister and found that the environment was of poor quality and decided not to admit her sister in the home. This information was passed on to the commission by the social services on the 16/10/06. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home must undertake an audit with the help of OT and EHO assessment of the premises in relation to the category of service users’ living in the home and implement the recommendations made in their reports. EVIDENCE: There were concerns with regard to the cleanliness and maintenance of the home that needed immediate attention. There was no evidence provided on this inspection regarding the Bedford borough council’s EHO food safety officer’s recommendation dated 11/04/06 for kitchen was implemented. COSSH checklist records indicated that the monthly routine checks were carried out on the 25/04/06 and 25/05/06 and there was no evidence that these checks were carried out there after. Hot water temperature checks were carried out on 28/03/06 and 20/04/06 and thereafter there was no evidence of these checks. Gas safety annual check was carried out on the 23/05/06 and thereafter there was no evidence of this check. Hoist test certificate dated Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 15 22/12/04 indicated that the home has 1 portable hoist and 1 fixed hoist in the bathroom. British healthcare traders association recommendation and advice dated 02/06/04 said ‘ meyra fixed bath hoist not tested unserviceable due to wear, rust & floor mountings’ there was no evidence on this inspection about the action taken to this effect. Water test certificate was dated 11/12/02 thereafter there was no evidence provided on this inspection with regard to consequent water tests. Risk assessment of the premises was carried out on the 15/04/02 thereafter no record of evidence was provided on this inspection. Bedroom number 5 and 1 beds and mattress need replacement with proper bed and mattresses, as they were found to be broken and uncomfortable for the service users’. Some of the cutlery that was used for the service users’ was chipped off and needed replacement. The home must undertake a through OT and EHO assessment of the premises in relation to the category of service users’ living in the home and implement recommendations made in their reports. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a good skill mix of staffs and work as a team. The home must ensure statutory checks prior to the appointments of the staffs’. EVIDENCE: The information regarding staffs’ training received was displayed on the notice board which included training in medication, fire awareness, health & safety, moving and handling, fire training and food hygiene. However, staffs training records were not made available on this inspection, as the staff member coordinating the inspection did not have access to the staff records. Staffs’ files were seen on this inspection and found that staff – 1 had clear CRB, references, and an application was available. This staff had discontinued her services. Staff –2 deputy manager CRB, references, staff contract and application was in order. Staff – 3 had CRB but in the name of different employer GCL care services dated 8/10/04. Her staff contract was dated 30/09/03 for commencement of service with Fenwick house. The date of employment with the home and the employers name referred in the CRB do not match and needed clarification. Manager’s employment contract, CRB, application was available except the references. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made efforts to provide good service delivery. However, the home must ensure to undertake pre-admission assessment, update medication records, carry out nutritional assessment, undertake OT and EHO audit, have robust statutory staffs checks and deploy at least one senior staff person around the clock to ensure the aspirations, needs and quality of life of the service users’ were promoted. EVIDENCE: In the light of the concerns that have been detailed under various outcome groups of this report, the management of the home appears to be adequate and had few areas for improvement, especially in the environment outcome group. The quarterly staffs’ supervision records were not made available on this inspection. The manager and the deputy manager were deployed from 7.00am to 3.00pm and there were no senior staffs available after 3.00pm Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 18 onwards. The home must revisit the staff deployment and reorganise staffing levels and duty in such a way that at least 1 senior staff member was available all the time, since the home was to provide 24hrs care and service to the service users’. The current business development plan presented on this inspection was dated 16/06/02. A blank comprehensive quality assurance questionnaire was provided on this inspection. However, there were no other details as to whom this questionnaire was sent, what has been the response and how the responses were used to improve the quality of care delivery in the best interest of the service users’. Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 19 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 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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 The home must undertake preadmission assessment of all new admissions and use the outcomes for preparation of the care plans. The home must ensure that the administartion of medication records were regularly updated. The home must undertake nutritional assessment of all the service users’ and implement the menus specific to individual service user’s dietary needs. The home must undertake an audit of the premises with the help of OT and EHO in relation to the category of service users’ living in the home and implement the recommendations made in their reports. The home must ensure statutory checks prior to the appointments of the staffs’. The home’s complaints policy DS0000063121.V311711.R01.S.doc Timescale for action 15/11/06 2. OP9 17(3) (1) 31/10/06 3. OP15 16 (2) (i) 30/11/06 4. OP19 23 (2) 23 (5) 16 (g) (j) 30/12/06 5. OP29 4(b) 31/10/06 6. OP16 22 (2) 31/10/06 Page 21 Fenwick House Version 5.2 and procedure must ensure in practice that the service users’ needs and aspiration were protected. 7. OP38 12 (1) (a) The home must ensure to undertake pre-admission assessment, update medication records, carry out nutritional assessment, undertake OT and EHO audit, have robust statutory staffs checks and deploy at least one senior staff person around the clock to ensure the aspirations, needs and quality of life of the service users’ were promoted. 30/12/06 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.V311711.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. Extracts may not be used or reproduced without the express permission of CSCI Fenwick House DS0000063121.V311711.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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