Inspection on 26/05/06 for Fermoyle House Nursing Home

This inspection was carried out on 26th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Fermoyle House Nursing Home 06/11/07

Fermoyle House Nursing Home 12/07/07

Fermoyle House Nursing Home 14/10/05

Fermoyle House Nursing Home 28/04/05

Fermoyle House Nursing Home 19/10/04

Fermoyle House Nursing Home 10/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Fermoyle House Nursing Home 121-125 Church Road Addlestone Surrey KT15 1SH Lead Inspector Mary Williamson Unannounced Inspection 26th May 2006 10:00 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 Fermoyle House Nursing Home DS0000017610.V297617.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. Fermoyle House Nursing Home DS0000017610.V297617.R01.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 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.V297617.R01.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 14th October 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 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. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by Mary Williamson who is the Lead Inspector for the home. The Registered Manager Angela Partridge was present throughout the inspection. There was opportunity to meet and talk with several service users during the visit. Some service users were able to comment about their experience living in the home in more detail then others. The service users being nursed in bed were well cared for and appeared comfortable. It was also possible to meet and talk with staff on duty. They were knowledgeable about the service users in their care and able to confirm various aspects of training they had 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. The inspector observed lunch being served and staff supporting service user to eat in a sensitive and caring manner. The inspector would like to thank the manager service users and staff for their help and hospitality during this visit. What the service does well: The home provided a good standard of care to service users by a competent and caring staff team. The home is well managed by an experienced manager in the best interests of the service users. She is also very committed to staff training and development. The housekeepers work well to maintain a good standard of cleanliness. The catering arrangements are satisfactory and meet the service users nutritional needs. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Prospective service users have the information necessary to enable them to make a decision regarding living at the home. Pre admission needs assessments in place are good. EVIDENCE: The home has produced a statement of purpose and service user guide, which is available to all prospective service users and their relatives enabling them to make an informed choice about living at Fermoyle House. The manager stated that very often a relative would make the choice of home on behalf of the prospective service user due to capacity. All prospective service users have a full pre admission needs assessment undertaken by the manager or a member of staff qualified to undertake this task. This also contains information gathered from relatives, other health care professionals and funding authorities. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 10 Assessments were sampled for EM, DH, KN, and KA. They were detailed informative, and included risk assessments for nutrition and skin care. A moving and handling assessment is also included. Dependency levels are evaluated as a result of these assessments. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to the service. Arrangements for personal care and health care needs are in place. The medication administration procedures safeguard the service users. EVIDENCE: Individual care plans are in place for all service users. Care plans for EM, DH, KN, and KA were seen. These are well maintained and are based on an assessment of needs. Risk assessments for moving and handling, nutrition, skin care, and restraint are also included in these plans. It was evident that regular reviews take place and the manager stated that care plan meetings take place every two weeks when five care plans are routinely reviewed. All service users are registered with a local GP who visits the home when required. Two service users confirmed that they could see a doctor when they need to. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 12 Chiropody is provided through home visits and the optician and dentist also visit the home. Access to specialist treatment is on referral by the GP and two service users are currently attending out patient clinic at Woking Community Hospital. The CPN also visits one service user every two weeks. There are no service users in the home with a pressure sore and access to a tissue viability nurse is available on request. Privacy and dignity is respected and staff were observed to knock on service users doors prior to entering their room. Screens are provided in shared rooms and service may also receive visitors in the privacy of their own room. Locks are not provided on bedroom and bathroom doors. Each service user has a risk assessment in place outlining the risk locks on doors would present. This issue continues to be monitored. The home has a policy in place for the administration of medication. Lloyds pharmacy supply all medication to the home and also undertake regular audits and provides training for staff. Tablets are provided in blister packs and all “out of cassette” medication is stored in individual labelled boxes. Medication recording charts are well maintained. A fridge for storing medication is located in the nursing office. A list of staff signatures who administer medication is also in place Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to the home. Activities in the home meet individual and collective needs. Family contact is maintained and the nutritional needs of the service users are also met. EVIDENCE: Activities provided in the home include board and carpet games with staff, hand massage and manicures, outside musical entertainers, Salvation Army band/choir, and community visits from the local school. One service user was having a hand massage undertaken by a member of staff and stated that it was “very relaxing”. There was a sing a long taking place in the small lounge before lunch and some service users in the large lounge stated they were content to sit and watch the garden. Some service users were being nursed in bed and it was noted that one service user who likes classical music had the radio in his room. Family links are maintained and visitors are encouraged into the home at any reasonable time. One service user stated that her family visit regularly and take her out. The manager stated that relatives are kept informed of any chance to service users treatment and condition. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 14 Lunch was served during the inspection, which consisted of fish, chips, and peas followed by fruit and custard. Staff were observed to collect the meals from the kitchen and serve the service users individually. The manager stated that about 70 of the service users required feeding. The staff carried this out in a sensitive and unhurried manner. Two ladies were very complimentary of the food in general. The cook will prepare an alternative meal for anyone who dislikes the choice of the day. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 15 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 excellent. This judgement has been made using available evidence including a visit to the service. The complaints procedure in place is available to service users, relatives and staff. The service users are safeguarded by the abuse awareness policy. EVIDENCE: The home has a complaints procedure in place and this is available to all service users relatives and staff. Two service users were asked if they were aware of how to make a complaint and they answered that “ they would never have to”. There have been two complaints since the last inspection both of which have now been resolved. The manager has developed an excellent training pack for staff on abuse awareness. She undertakes teaching sessions for staff and provides them with a copy of this pack, which also contains a written test to determine competence. There is also a copy of Surreys Multi Agency Policies and Procedures on the Protection of Vulnerable Adults in place and the manager has attended training and updates in these procedures. Fermoyle House Nursing Home DS0000017610.V297617.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, and 26. Quality in this outcome is poor. This judgement has been made using available evidence including a visit to this service. The programme of routine maintenance and the renewal of the fabric and decoration of the premises as a requirement from the last inspection has improved the physical character in part of the home. This programme must continue, in order to provide service users with comfortable surroundings and meet the environmental standards of the home. EVIDENCE: The new carpet in the main hallway, stairs and upstairs hallway has improved the physical appearance to this section of the home. It was also pleasing to note that some bedrooms have been redecorated and new furniture provided. During the inspection a contractor visited the home to quote a price to replace all external windows, which are rotten and need to be repaired, repainted or replaced. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 17 The general gloss paintwork to skirting boards and doorframes needs to be addresses as this is badly damaged from wheelchair traffic. The standard of floor covering in the back hallway is poor and needs to be replaced. The carpets in room 9 and 10 on the same hallway need carpet grips, as these are fraying and present as a potential trip hazard. All the bedrooms in this section of the home need to be refurbished. All the fire doors throughout the home need adjusting as they bang and cause disturbance to service users during the night. This is a requirement from the previous inspection on 14/10/2005. The home has the required amount of toilets and bathrooms situated throughout the home. Due to mobility needs of the service users some of these bathrooms are unable to be used. There is an assisted bathroom on the first floor and an assisted shower room on the ground floor for service users use. This is an ongoing issue and will continue to be monitored as the mobility needs of service users change. The manager stated that a new Solus Combi stand and lift hoist was on order to assist with moving and handling. Other equipment available includes wheelchairs, raised toilet seats, commodes; grab rails, hoists, call bells and walking frames. Ramps provide access to the garden and a shaft lift provides assess to the first floor. Mal odour in one bedroom needs to be kept under control. Fermoyle House Nursing Home DS0000017610.V297617.R01.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 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 poor. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff are adequate to meet the assessed needs of the current service users. The recruitment practice of the home does not safeguard service users living there. EVIDENCE: The staff duty rota was seen and this indicated the skill mix and number of staff on duty was adequate to meet the service user needs. On the day of the inspection there was one qualified nurse, six carers, one cook, one kitchen assistant, two cleaners, and one laundry assistant on duty. It was possible to talk with three members of staff who were able to confirm some of the training they had undertaken, and how they use this training to care for the service users. Training records were seen and includes, induction training for all staff. 33 of staff have NVQ, six staff have NVQ Level2 and two staff have NVQ Level3. Currently there another two staff undertaking NVQ level 2. Recruitment records were seen for three staff members. These were generally well maintained, however two files had no evidence that CRB (Criminal Records Bureau) disclosures had been undertaken. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 19 Fermoyle House Nursing Home DS0000017610.V297617.R01.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 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 good. This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership and management input ensuring that service users needs are met. Health and welfare of service users are promoted. EVIDENCE: The registered manager is a qualified nurse with considerable experience in the provision and delivery of care to older people. She has almost completed her NVQ Level 4 in management. She is also a qualified manual-handling instructor and undertakes all the moving and handling training for the staff working in the home. A competent team of qualified staff one of whom is an NVQ assessor supports her. The provider undertakes the financial management and some of the administration in the home. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 21 The manager stated that quality assurance letters are sent to relative asking them to make comments regarding their experience of the home. She also stated that due to capacity it was difficult for service users to complete customer satisfaction questionnaires. The manager demonstrated a quality performance indicator on self- evaluation of the national minimum standards. She completes this as a team effort taking an individual standard and discussing it with the staff at meetings. There is a wide range of policies and procedures relation to health and safety in place. All staff have training in these policies and procedures during induction training which recorded on their training files and includes food hygiene, first aid, fire safety, control of infection, manual handling, and risk assessment. COSHH procedures are observed. The fire safety records were seen and these are well maintained. The fire alarms are checked weekly and recorded. Fire fighting equipment is maintained by contractors and records kept. The procedure for recording accidents is good. Fermoyle House Nursing Home DS0000017610.V297617.R01.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 2 3 2 3 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 2 3 Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 OP19 OP24 2. 3 OP26 OP29 16(2k) 19(4)(b) Regulation 23(2d) Requirement Timescale for action 20/07/06 8. OP37 17(3)(b) The registered person shall ensure that all parts of the care home are kept reasonably decorated to include carpets. The registered person must keep 20/07/06 the home free from offensive odours. The registered person shall not 20/07/06 allow a person to work in a care home unless he has obtained all the documents specified in Schedule 2 to include a CRB disclosure. The registered person must 20/06/06 ensure that records referred to in Schedule 2 are kept in the care home and available for inspection. Fermoyle House Nursing Home DS0000017610.V297617.R01.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 Refer to Standard OP21 Good Practice Recommendations The registered person must ensure that a sufficient number of useable bathrooms are provided in the home and consideration should be given to this when the old bathrooms are due for refurbishment. Fermoyle House Nursing Home DS0000017610.V297617.R01.S.doc Version 5.2 Page 25 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.V297617.R01.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. 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!