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Inspection on 14/10/05 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 14th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

The home provides good quality of care to service users by staff in a kind and caring manner. The home is well managed by a manager who is very committed to staff training and development. The catering arrangements are well organised and the food provided is wholesome, appetising and nutritious. Both housekeepers work well to ensure a good standard of cleanliness.

What has improved since the last inspection?

Since the last inspection the small lounge has been redecorated and a new carpet fitted. The service users who use this lounge were very apprechiative this. Three bedrooms, and the back stairs and landing have also been re-carpeted. More leisure activities have been introduced to the activity a programme. Regulation 37 notices are being sent to the Commission for Social care Inspection. .

CARE HOMES FOR OLDER PEOPLE Fermoyle House Nursing Home 121-125 Church Road Addlestone Surrey KT15 1SH Lead Inspector Mary Williamson Announced Inspection 14th October 2005 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 Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V258973.R01.S.doc Version 5.0 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) 01784 482570 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.V258973.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 32 beds providing nursing care for older persons from the age of 60 years 28th April 2005 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 of Addlestone 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 small dining area. The garden to the rear of the property is well maintained and is overlooked from the lounge. Car parking is available to the front of the home. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and the second to be carried out in The Commission for Social Care Inspection year 2005/2006. Mary Williamson the Lead Inspector for the service undertook the Inspection. Mr Raj Gokhool Regulation Manager accompanied Mary Williamson for the first part of the inspection. Mrs. Angela Partridge the registered home manager and the provider Mr. Graham Samuel were both present throughout the inspection. Several of the service users and staff were spoken to during the day. No service user comment cards, relative/visitors comment cards, or visiting professional comment cared were returned prior to the inspection or since the inspection. There were no visitors or relatives in the home while the inspection was being undertaken. A tour of the premises was undertaken, and records relating to the care of the service users and the management of the home were examined. Staff were interacting with service users in a caring and professional manner. Some staff were supporting service users in the small lounge during a sing along to some old time music. A fish and chip lunch was being enjoyed by all. The inspectors would like to thank the service users, staff and management for their helpful approach to the inspection. What the service does well: The home provides good quality of care to service users by staff in a kind and caring manner. The home is well managed by a manager who is very committed to staff training and development. The catering arrangements are well organised and the food provided is wholesome, appetising and nutritious. Both housekeepers work well to ensure a good standard of cleanliness. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home could improve the physical character of the home by introducing a programme of routine maintenance and renewal of fabric. Trained staff should have regular updating in the administration of medication. The recruitment of staff must ensure the safety of service users by following the homes procedures. All the required documentation must be in place to include two written references. Please contact the provider for advice of actions taken in response to this Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 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 Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Assessment procedures are in place to determine the suitability of the prospective service user. EVIDENCE: The manager stated that she undertakes a pre admission needs assessment on all prospective service users and the information gathered will determine the suitability of the placement. A selection of pre- admission needs assessments were sampled during the inspection. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 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. Individual care plans are in place, which contain all relevant information. Effective systems are in place to ensure service users health care needs are met. The administration of medication in the home highlighted poor practice. EVIDENCE: Individual care plans are in place, which are well maintained. These plans are formulated from the pre admission assessment, input from the service user whenever possible, information from relatives, and multidisciplinary team reports. The manager stated that care plan meetings take place every two weeks when five plans are reviewed each time. All the service users are registered with a local GP who visits the home on a regular basis. Service users also have access to a dentist, chiropodist, and an optician who also provide home visits. There is also support from the tissue viability nurse, and community psychiatric nurse if required. Physiotherapy can be arranged privately. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 11 The manager stated that currently there are two service users in the home with pressure sores. Treatment is carefully monitored and effective pressure relieving equipment in place to promote healing. Locks are not provided on bedroom or bathroom doors. Each service user has a risk assessment in place outlining the risks locks on doors would present. This issue continues to be monitored. Shortfalls were highlighted in the standard relating to medication. One service user was observed in her bedroom having spat out her partly chewed medication onto her clothing. A medicine pot containing liquid medicine was also observed on the service users bedside table not having been taken. This procedure is not in line with the homes administration of medication policy or the MNC Code of Conduct and must be reviewed immediately. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 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, and 15. Service users living at the home are provided with a programme of activities based on individual and collective needs. Family contact is maintained and encouraged. The catering arrangements are satisfactory and well managed. EVIDENCE: On the morning of the inspection eight service users were enjoying a sing along to old war- time music in the small lounge. This was overseen by the staff on duty. Fourteen service users were sitting in the large lounge with back round music provided for relaxation. The manager stated that two new activities of flower arranging and hand massage have been introduced to the activity programme, which also included board games, painting, colouring, music and gentle exercise. The provider stated that musical entertainment is provided monthly. Children from the local school visit six times a year and there are also visits from the local clergy. Family links are maintained and visitors are welcomein the home at any reasonable time. There were no visitors in the home during the inspection. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 13 The catering arrangements in the home are good. Lunch was observed during the inspection, which consisted of fish, chips, and peas followed by pear sponge and custard. Special diets are catered for with several service users requiring a soft diet and support with feeding. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, and 18. The home has a complaints procedure in place that is made available to service users, relatives and staff. A procedure for responding to allegations of abuse is in place. EVIDENCE: The home has a complaints procedure in place and a copy of this is available to all service uses and their relatives on admission to the home. There is an abuse awareness policy in place and the manager and the provider stated that all staff have training in this procedure during their induction period. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24, and 26. The physical character of the home would benefit from a detailed programme of routine maintenance and renewal of fabric. This will provide the service users with comfortable surroundings and meet the environmental standards within the home. EVIDENCE: It was reassuring to observe the small lounge has been redecorated and benefits from a new carpet since the last inspection. The service users who use this lounge were most appreciative of this. The general paintwork throughout the home needs to be reassessed as this is badly damaged from wheelchair traffic. The standard of floor covering throughout the hallways and the front hall and stairs does not meet the environmental standards of the home and needs to be replaced. • Room 28 requires a new carpet. • Room 24 needs to be redecorated and the damage to the plaster on the wall caused by the cot sides needs to be repaired. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 16 • • • • • The bed table in room 16 needs to be replaced as this is beyond repair. The damage to the ceiling in room 23 caused by a leak in the roof needs to be repaired. The frayed carpet between the assisted bathroom and room 22 needs attention, as this is a potential trip hazard. The crack in the plaster outside room 19 needs to be repaired. All the fire doors need to be adjusted as they bang and cause disturbance during the night. For standard 21 pleas see previous inspection report dated 28/04/05. Service users accommodation is provided in single and shared rooms, none of which have en-suite facilities. These rooms are adequately furnished and have been individualised with personal items of furniture and belongings. Specialist equipment is in place to support the assessed mobility needs of the service users, for example hoists, wheelchairs, raised toilet seats, commodes, grab rails, ramps and a shaft lift to provide access to the first floor. Two housekeepers work hard to ensure the home is clean and free from offensive odour. This would be more evident if there was a programme of refurbishment in place. There is a control of infection policy in place, and all staff have been trained in these procedures. Currently there are three service users in the home with MRSA infection and staff spoken to were able to demonstrate how to follow the correct procedures when dealing with infection. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, and 30. The numbers and skill mix of staff, who have been trained to a competent level, meets the service users needs. EVIDENCE: On the day of the inspection there were two qualified nurses and five care staff on duty. There were also two cleaners, one laundry assistant, one cook, and one kitchen assistant. The staff were interacting with service users in a positive and caring way. All the service users spoken to were most appreciative of the staff and the care they provide. The manager stated that all staff undertake induction training and this is recorded on individual development profiles. She also stated that seven staff have undertaken NVQ level 2 and two staff have undertaken NVQ Level 3. The home has a recruitment and equal opportunities policy in place. Two staff employment recruitment records were seen. Most of the required documentation was in place. However there was one written reference outstanding and this was discussed with the provider and manager. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 18 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, and 38. The home benefits from good leadership and management input ensuring that service users needs are met. The health and safety of service users are promoted. EVIDENCE: The registered manager is a qualified nurse with considerable experience in the provision of care to elderly people. She is currently undertaking her NVQ Level 4 in management. Since the last inspection she has undertaken a training course to be the manual handling instructor for the home. All staff including the night staff have now received current updating in manual handling procedures. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 19 Health and safety policies and procedures are in place. All staff receive health and safety training during induction for example, fire safety, food hygiene, first aid, control of infection, and risk assessment and management. The fire records were seen and are well maintained. The procedure for the recording of accidents is also good. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X 2 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 21 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 9 Regulation 13(2) Requirement The registered person must ensure that medication is administered safely and correctly. The registered person shall ensure that all parts of the care home are kept reasonably decorated, to include the provision of new carpets. The registered person must not employ staff to work at the home unless all the required documentation is in place to include two written references. Timescale for action 14/10/05 2 19,20, and 24 23(2)(d) 01/12/05 3 29 19(1)(a) 01/12/05 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 Good Practice Recommendations Standard 19, 20, and It is recommended that the provider submits an action 24 plan to The Commission for Social Care Inspection by 01/12/05. This action plan should outline a detailed programme of DS0000017610.V258973.R01.S.doc Version 5.0 Page 22 Fermoyle House Nursing Home decoration and refurbishment, and realistic time scales for this work to be undertaken. This plan should include all the shortfalls identified in the environmental standards of the report. Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Fermoyle House Nursing Home DS0000017610.V258973.R01.S.doc Version 5.0 Page 24 - 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!