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Inspection on 12/07/07 for Fermoyle House Nursing Home

Also see our care home review for Fermoyle House Nursing Home for more information

This inspection was carried out on 12th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Comments made by service users on the first visit were complimentary about the home. Seven surveys that the manager had sent to the relative or representatives were also complimentary saying ` staff are always pleasant and friendly` and `we are happy with the way our mother is cared for`. The home has a consistent staff and management team, which benefit all individuals, who live at the home. When the manager is present in the home she is responsible for the activities that take place and ensuring that there is a published programme. The manager is also responsible for the staff training.

What has improved since the last inspection?

Four requirements were made following the inspection in May 2006 and three have now been met and one partially. The home has now replaced many of the carpets in the home and the offensive odours were not present on either of the two visits in July. Recruitment practices are now followed and all documents stored at the home and available for inspection.

What the care home could do better:

As a result of this site visit seven requirements have been made and can be seen in more detail at the end of the report. The home needs to update their current service user guide and statement of purpose and make these available to the service users and send a copy to the Commission. All service users need to have detailed individualised care plans and risk assessments completed and they must be reviewed regularly. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Safeguarding adult training must include all members of staff. Consideration should be taken to refurbish the current bathrooms in the home to ensure they can meet the needs of the current service users and the programme of decoration should continue. The home should ensure that work experience school children are given the necessary training for them to be able to carry out the tasks that are requested of them.

CARE HOMES FOR OLDER PEOPLE Fermoyle House Nursing Home 121-125 Church Road Addlestone Surrey KT15 1SH Lead Inspector Lesley Garrett Unannounced Inspection 09:30 12 July 2007 & 18th July 2007 th 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 Fermoyle House Nursing Home DS0000017610.V345498.R02.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. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fermoyle House Nursing Home Address 121-125 Church Road Addlestone Surrey KT15 1SH 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) 01932 849023 01932 847183 Pinebird Ventures Limited Miss Angela Rosemary Partridge Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 32 beds providing nursing care for older persons from the age of 60 years 4th September 2006 Date of last inspection Brief Description of the Service: Fermoyle House has been adapted to provide accommodation and nursing care for thirty-two service users who are elderly. The home is located in a residential area within easy access to the local shops and community facilities. There is also access to a local bus service. Accommodation is provided in single and shared rooms. The home has two lounges, and a dining area. The garden to the rear of the property is well maintained and is overlooked from the lounge. Car parking is available at the front of the home. The fees for this service range from £449.17 per week and £575 per week. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’ and was undertaken over two days. The inspector arrived at the service on the 12th July and 18th July at 0930 and 1030 respectively and was in the service for a total of 9 ½ hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner and manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. No completed surveys were retuned to us from the service users, relatives, representatives or other health care professionals. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. What the service does well: What has improved since the last inspection? Four requirements were made following the inspection in May 2006 and three have now been met and one partially. The home has now replaced many of the carpets in the home and the offensive odours were not present on either of the two visits in July. Recruitment practices are now followed and all documents stored at the home and available for inspection. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 6 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. Fermoyle House Nursing Home DS0000017610.V345498.R02.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 Fermoyle House Nursing Home DS0000017610.V345498.R02.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): 13&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have all the information they need to make an informed choice about where to live. All service users have a pre-admission assessment to ensure that their needs can be met prior to admission to the home but not always by a suitably qualified individual. EVIDENCE: On the first visit the provider told us that all service users have an assessment prior to their admission to the home. He told us that he was going to the hospital that day to do an assessment himself as the manager was on annual leave. A suitably qualified individual should do all pre-admission assessments for the home therefore a requirement will be made at the end of the report. During the second visit the manager showed us the form used for the preadmission assessments, which took into account all the activities of daily living. We observed that these assessments had been completed but filed separately to the individual service users folders of care. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 9 We sampled an individual plan of care for a recently admitted service user and found that the assessment process had not been completed. The service user had no risk assessments for manual handling, skin integrity or nutrition making this service user vulnerable due to the diagnosis of this individual. We asked the proprietor to provide us with their recent statement of purpose and service user guide to reflect the new regulations that were added in July 2006. The proprietor showed us the homes brochure and stated this was also their statement of purpose. On the return visit the manager had written a new statement of purpose but this also did not reflect what was required in Regulation 5 schedule 1 of The Care Homes Regulations 2001 and a requirement has been made to send a copy of this to CSCI. The home does not provide intermediate care. Fermoyle House Nursing Home DS0000017610.V345498.R02.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users have individual plans, which did not fully reflect the care and support that the service users required. The medication policies and procedures that are in place and implemented by staff protect service users. EVIDENCE: On the first visit three service user plans of care were sampled and a further one on the second visit. All contained care plans but these were not sufficient to clearly demonstrate the support that each service user required and some had not been individualised. Some risk assessments had been completed but they had no evidence in the folders of reviews. The manager stated that a sample of care plans is reviewed every two weeks at meetings. The minutes of these meetings were shown to us but the information had not been transferred to the individual plans of care. There was no evidence in the individual plans of care that risk assessments for the use of bedrails were in place. The home had gained consent from the Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 11 relative and a medical device alert for bedrails was filed separately to the individual plans. A service user is receiving food via a PEG tube. The information available about this equipment is the standard information provided by the dietician or speech and language therapist and no individual detailed care plan or risk assessment was in place for this service user. The The and this manager stated that the home has two service users with pressure sores. home does not use a recognised tool for the assessment of these wounds from the care plans for one particular service user it was not clear how wound was treated. The care plans in the home are fragmented and information about each service user is kept in different folders and a requirement will be made at the end of the report. The care plans and risk assessments must contain details in sufficient depth to enable staff to deliver individualised care and contain action to be taken, the outcomes of these actions and evidence of consultation with service user and their representatives. The provider told us that the service users are registered with a local General Practitioner (G.P.) who will visit the home when needed. If the service user requests and the G.P. are willing the provider stated that service users could retain their own G.P. The home also has the support of visiting optician’s dentist and chiropodist. The registered nurse on duty during the first visit explained to us the procedures for the administration of medicines. This was not looked at in depth, as she was busy organising the recent delivery of medicines from the pharmacy. The local pharmacy delivers medicines every month to the home and blister packs are used. Three medication administration records were sampled and two recommendations have been made at the end of the report concerning the recording of non-administered medicines and advice of one particular medicine that is given via a PEG tube. The manager showed us the privacy and dignity policy that the home uses. During the tour of the building we observed staff knocking on the doors. Fermoyle House Nursing Home DS0000017610.V345498.R02.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is not clear if the social and recreational activities meet the service users expectations. Service users receive an adequate diet but not in pleasing surroundings. EVIDENCE: The provider told us that the manager provides the activities in the home in consultation with him. He stated that they both plan the programme and then book the entertainment. No activities programme was displayed and the provider could not locate this. We visited the home on two different days and did not see evidence of activities in progress. The provider told us he did not know what activities had been arranged for that week. The provider stated that a bus trip to Brighton had been organised by his other home and a few spaces were available. It was offered to the service users but no one wanted to go. The provider told us that children from a local school visit the home to chat to service users after school. These children also take up work experience at the Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 13 home. The provider told us that they will shadow a carer but do not deliver personal care. One of the tasks is that they help to feed the service users at meal times but are always supervised. He stated they are usually children aged sixteen and under. A requirement has been made that all volunteers have suitable training for tasks they are to undertake. The provider stated that choice is given to service users for all their daily activities for example when to get up in the morning and when to go to bed at night. On the day of the first site visit it was observed that the majority of the service users on the first floor were up washed and dressed. The registered nurse stated that the night staff helps with this in the morning and the day staff arrive at 0700. In the four care plans sampled no evidence could be seen of these preferences. We observed some of the lunch time period and noted that the home has very little space on the dining area to accommodate service users therefore most of them have their meals sitting in the two lounges and in their bedrooms. All staff helps with the feeding including the housekeeper and the work experience schoolboy. It was observed that service users are given bibs and one service user told us it was to protect their clothes. The home has a four-week menu plan and during the site visit we looked at this. It was observed that the supper menu is practically the same each week with only a change on one day. The provider stated that the supper menu is broader that that stated. It is recommended that the manager in consultation with the cook look at the supper menu to see if this needs adjusting to ensure there is variety in the meals. One service user told us ‘the foods lovely I could lick my plate’. The environmental health officer visited in April 2007 and made a requirement about the kitchen. Staff have to walk through this kitchen to gain access to the staff room and the provider and managers office. This practice could be an infection control issue but no requirement has been made as the environmental health department has already made a requirement in their report. We observed that the cook that was on duty the day of the first visit had a basic food hygiene certificate that had been completed in 2003. She told us that she had completed a longer course more recently than that and this qualification was valid for life and required no further updating. It is recommended that the manager clarify this with the college where the course was undertaken and provide further training if necessary. Fermoyle House Nursing Home DS0000017610.V345498.R02.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not protected by the homes policies for dealing with complaints and safeguarding procedures do not protect service users from harm. EVIDENCE: The provider told us that the home has never received a complaint therefore no complaints log is necessary. We saw survey forms were sent to relatives in 2004 and one stated that the cobwebs at the front door did not make the home welcoming and one form stated that staff were not friendly and no information was available about her mother between visits. These are two examples of comments made by relatives but no documented action taken. On return to the home on the second visit the manager had started a complaints and compliments log, which she showed to us. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The provider was not aware of the local authorities procedures on safeguarding adults and when asked if the home had these procedures he made a telephone call to locate them. The homes policy does not reflect these procedures and it was recommended that the policy be reviewed. On the Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 15 second site visit the manager showed us that the policy had now been changed. The manager stated that she provides the training for the staff on adult protection and she had accessed the local authorities training. We observed in the recruitment folders sampled that training had taken place. On the day of the second site visit matters raised about members of staff attitudes and care practice during the inspection led to a safeguarding referral being made by the commission. Following this referral we have since heard that this matter will not be proceeding under the safeguarding procedures and no further action will be taken. During the first site visit the provider told us that he carries out some preadmission assessments and is in daily contact with the home. It is a requirement that he undertakes the safeguarding adults training along with any volunteers to the home. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 16 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 poor. This judgement has been made using available evidence including a visit to this service. People who use the service do not live in a well-maintained, decorated environment. EVIDENCE: We undertook a tour of the building and started with the upstairs. The bathroom and toilet upstairs was of a poor quality. The nurse told us that service users were unable to access the bathrooms or toilet on this level so all have to use the shower downstairs. The bathrooms on the upper level have never been re-furbished to meet the needs of the changing needs of the service users. The bath was full of water and bleach and commode pots were soaking in there. We were told that this was to ensure that they were cleaned thoroughly. The provider was made aware of this at the time and the bath was emptied immediately. A recommendation was made at the last site visit in May Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 17 2006 for the home to ensure that there were enough usable bathrooms and this will now be a requirement. Some of the bedrooms had been personalised by the service users but rooms still needed to be decorated and re-furbished. The provider stated that rooms are decorated when the residents have vacated the rooms. A requirement will be made at the end of the report for a programme of decoration to take place and this was also a requirement following the last site visit in May 2006. Since the last visit in 2006 some carpets have been replaced and the provider stated that he is about to replace all of the outside windows. Some of the bedrooms and corridors were dark and consideration should be given to improve the lighting especially in the communal areas and corridors to benefit those service users with poor eyesight. One corridor upstairs had a portable heater and we were told that there is no radiator available and therefore this can become cold in the winter. It has been recommended at the end of the report for the temperature in this corridor to be monitored to ensure that there is adequate heating or ventilation depending on the weather. The majority of the beds can be raised and lowered and we observed that pressure-relieving mattresses were available for the comfort of the service users. One service user that spoke to us when she was in the lounge stated ‘it is nice here, we’re all happy here, always lovely and clean’. The home has well-maintained gardens with access for service users from the lounge. The home has a laundry it has washing machines and a drier. We observed that a sluice is also sited in this building but the provider stated that it is not used. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home receive some training but are not always in sufficient numbers to fill the aims of the home and meet the changing needs of people who use the service. EVIDENCE: On the day of the site visit the manager was on annual leave and there was on nurse in charge supported by some carers. The provider stated that staffing numbers never vary only if the numbers increase. On the second day we had the opportunity to speak with the manager who stated that she had recruited another nurse to support the team so that they were not so reliant on the bank staff. Due to the lay out of the building and the observed dependency levels of the service users it is a requirement that the manager assess the dependency levels of the service users and adjust the staff numbers if needed. The manager states in the completed AQAA, which is a self assessed quality document, that the home has a low turn over of staff and do not use agency staff. There was no extra staff at peak times all categories of staff help at lunch to assist with feeding the service users. It is a requirement at the end of the report that all volunteers who assist with feeding have received the appropriate training to support them in this practice. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 19 The provider told us that three members of staff have the National Vocational Qualification (NVQ) in care at level 2 and three members of staff are undergoing training. Members of staff fund this course themselves but other in-house training is provided. The manager stated that she provides the training for staff in the home and her AQAA stated that they would encourage staff to attend the training days and to do the NVQ training. We sampled three staff recruitment folders and found that most of the information required was in place but a recommendation has been made that the folders are reviewed to ensure all documentation is in place. During the first visit there was no evidence in the folders that any induction for new members of staff had taken place or evidence of supervision. The provider told us that he does not agree with supervision sessions because the staff are supervised daily. He later found the supervision folder that is kept separate to the staff folders and the manager stated on the second visit that she does these sessions with the staff. The manager also showed us the documentation, on the second visit, of the induction training that takes place in the home. This is also kept separately to the staff folders. The home follows a nationally recognised induction programme that is linked into the NVQ programme. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 20 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. The registered people in the home need to keep up to date with changing legislation and trends in current practice to safeguard the service users. EVIDENCE: On the second visit we had the opportunity to speak with the manager who stated that she has been the home’s manager for over three years and has completed her registered managers award. She is responsible for the training within the home and has her train the trainer award. She stated that she keeps updated with her knowledge in accordance with her professional qualification. In the AQAA returned to us she states that she is extremely experienced and competent in the care of the elderly and is fully supported by the provider. It also states that that she keeps up with changing legislation but Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 21 the home was not aware of the July 2006 changes to the regulations and had no copy in the home to refer to when updating the service users guide and statement of purpose. The manager stated in the returned AQAA that what she could do better is spend less time completing ever increasing paperwork and spend more time on the floor keeping updated with the residents well being. The manager has three significant roles within the home as the registered manager, activities co-ordinator and the training facilitator. Survey forms were sent to a selection of service users and their relative or representative and included other professionals involved in their care. No survey forms were returned to CSCI and therefore cannot be used for the purpose of this report. The manager had recently sent survey forms to all the relatives and received seven replies which was shown to us. Comments on the surveys were favourable and included ‘I find the manager nursing staff and carers very considerate and understanding’. Another said ‘always a member of staff available when I need to ask about my wife’. There was one comment that commented on the same thing that was mentioned on the last survey that was completed in 2004 and that was that there was spiders and cobwebs at the front door. The manager stated this has now been actioned and written up on the new complaints/compliments log. The provider stated that the home does not have service user meetings to share information about the home, as no service user is capable of understanding that. The provider told us that no service user money is kept at the home. If they need anything the home will purchase it then invoice them the provider said. The provider stated that all the health and safety checks are carried out and certificates are available. The gas certificate is dated July 2007. The engineer to test fire alarms and equipment visit four times a year and the last visit was May 2007. The fire alarms are tested weekly by the manager and documented. The manager was on annual leave on the day of the first site visit and it was observed that the alarms had not been tested therefore the provider stated that he would do them. The provider said that the home has a maintenance person and he is responsible for all of the portable electrical appliance testing. The documentation for this was not sampled. Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 22 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 23 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 2 Standard OP1 OP7 Regulation 4, 5 & schedule 1 15 Requirement Please write a statement of purpose and service user guide and provide a copy to CSCI. All service users to have detailed care plans and risk assessments and these are to be reviewed regularly. All members of staff including volunteers must undertake safeguarding adult training. All parts of the care home should be kept clean and reasonably decorated. The home should provide enough usable bathrooms and toilets that are suitable for the needs of the service users. To ensure that staffing levels meet the dependency needs of the service users and that staffing levels are reviewed regularly. All members of staff including those employed on a temporary basis to include work experience school children have the appropriate training for the work they are to perform. Timescale for action 18/08/07 18/08/07 3 4 5 OP18 OP19 OP21 13 (6) 23 (2) (d) 23 (2) (j) 18/08/07 18/10/07 18/10/07 6 OP27 18 (1)(a) 18/08/07 7 OP30 18(1)(b) & (c)(i) 18/08/07 Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP8 OP9 OP9 OP15 OP15 Good Practice Recommendations It is recommended that the home uses a recognised tool to assess any pressure sores in the home and to consult with their local tissue viability nurse for advice. It is recommended that when a medicine is not administered this is recorded. It is recommended that the home speak to their pharmacy to clarify the administration of one particular tablet via the PEG tube. It is recommended that the manager discuss the supper menu with the cook to ensure variety and nutritional value. It is recommended that the manager checks with the local college/ environmental health office that the cook’s certificates are valid for life and no further updates are required. It is recommended that the lighting in the home is assessed and for this to be improved where necessary It is recommended that the heating in the upstairs corridor be monitored at all times to ensure there is adequate heating and ventilation depending on the weather. It is recommended that the home consults with the appropriate authority to check the use of a sluice in the laundry area. It is recommended that the recruitment folders be reviewed to make sure that all information required is in place. 6 7 8 9 OP25 OP25 OP26 OP29 Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Fermoyle House Nursing Home DS0000017610.V345498.R02.S.doc Version 5.2 Page 26 - 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. 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