Inspection on 14/09/05 for Fern Court

This inspection was carried out on 14th September 2005.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fern Court 30/11/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Fern Court Down Hatherley Lane Down Hatherley Nr Gloucester Glos GL2 9QB Lead Inspector Ms Lynne Bennett Announced Inspection 14th September 2005 09:30 Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 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 Fern Court DS0000062152.V249410.R02.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 Adults 18-65. 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. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fern Court Address Down Hatherley Lane Down Hatherley Nr Gloucester Glos GL2 9QB 01452 731984 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) New Beginnings (Gloucester) Ltd Alan Gilbert Howe Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Registered Manager must complete the Registered Managers Award by 31 December 2005. Ferncourt is a Care Home for 8 YA LD Date of last inspection NA Brief Description of the Service: Fern Court is a residential care home for 8 people with a learning disability and associated challenging behaviours. The home opened in May 2005. Fern Court is one of three homes in Gloucestershire owned by New Beginnings. Fern Court is a large Victorian House that has been fully refurbished to provide single rooms with en suite facilities. People living at the home have access to two lounges and a dining room and large well maintained gardens. Fern Court is situated in open countryside between Cheltenham and Gloucester. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This first inspection took place on a day in September 2005 starting at 9.30 and finishing just before 18.00. This inspection was undertaken by two inspectors. All people who live at the home were present at times during the day and five were spoken to about their care. Comment cards were received from four people living at the home and three of their relatives. A tour of the communal areas was conducted as well as two rooms of people living at the home. A range of records were examined including care plans, medication forms, health and safety records and staff files. Policies and procedures were sampled. The registered manager was present throughout and feedback was given to the group manager. Four staff were spoken to about the care they provide and about their roles and responsibilities at the home. An immediate requirement was issued to Fern Court in relation to the admission of a person outside of their category of registration. What the service does well: What has improved since the last inspection? What they could do better: The registered person must ensure that the home operates within its categories of registration and that people living at the home have a learning disability. There must be a thorough and comprehensive admissions process in place. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 6 Medication systems must be improved to reduce the risk of errors occurring. There must be a review of the transport provided to ensure that people living at the home have appropriate access to a range of regular social, educational and recreational activities. The registered person must ensure appropriate levels of staff as identified in the care plans of people living in the home. 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. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4. The admissions procedure needs to be significantly improved to ensure that the home is providing care to people with a learning disability and so operating within its categories of registration. EVIDENCE: The home has a Statement of Purpose and Service User Guide that were developed for registration. These documents have not yet been reviewed. The home has admitted a person with mental health needs and associated problems. According to their Psychiatric Report this person does not have a learning disability diagnosis. The registered manager stated that a verbal assurance had been received from the placing authority that the person has a learning disability but there was no assessment to support this. An immediate requirement was issued stating that this must be resolved within 7 days or further action will be taken. The registered person must ensure that people admitted to the home comply with their registration status and with their aims and objectives as identified in the Statement of Purpose. There have been five new admissions to the service since May 2005 and one person has moved across from another home in the organisation. People are offered the opportunity to visit the home for informal visits, tea visits and possibly overnight stays before making the decision to move into the home. At present the registered person is not keeping a record of these visits and it is recommended that this be done as part of the admissions process. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 9 The home receives information about prospective residents from the placing authority. Copies of Adult Care Plans and Health Needs’ Assessments were examined. The registered manager and group manager also conduct visits to the home of people wishing to move to the home to conduct their own assessment. There was no evidence of the home’s own assessment and it is recommended that a tool is developed to complement assessments received from placing authorities. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. An improvement in care plans and risk assessments will ensure that staff have access to the information they require to meet the needs of people living at the home. People living at the home are provided with information and assistance to make choices and decisions about their lifestyles. EVIDENCE: The care for three people was case tracked. This included meeting them, examining their records, talking to them about their care and the home and looking at their rooms. Staff were spoken to about the care they provide for these three people. Staff complete a Pathways Assessment when people move into the home. Care plans for the people case tracked were inconsistent with other care plans sampled. One person had care plans from another home in the group. These now require reviewing and amending to reflect the care being provided at Fern Court. Staff, the registered manager and daily notes indicate that there have been considerable changes to patterns of behaviour since the move and care plans need to reflect this. Another person has recently moved into the home and care plans provided by the placing authority were being used whilst the Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 11 home was developing its own care plans. Care plans for the third person are being regularly monitored and reviewed. Staff spoken with appeared to be aware of the identified needs of these people and how they should be supported. Staff were observed following care plans during the day. Care plans must be put in place for people living at the home as indicated. People living at the home were observed making decisions about activities of daily living. People were asked if they wished to take part in the morning and afternoon activities. One person confirmed that there are regular house meetings where ideas for meals, activities and the home are discussed. It was evident from the minutes that these are being actioned wherever possible. Any restrictions to freedom of movement or choice are recorded in care plans. For instance the kitchen door has a keypad because one person is at risk in the kitchen and another finds it difficult to control the amount of food they eat. This does not deny access to the kitchen for other people in the home. Staff will support them. Financial records were not examined although there was general discussion about the management of finances. One person was observed making choices about how they wish to spend their money and another person was observed being supported to manage their finances. Risk assessments are in place for one-person case tracked and these are being regularly reviewed. Sampling of other risk assessments indicated that this was happening for other people living at the home. The risk assessments for the other two people need to be put in place to reflect the hazards they face whilst living at Fern Court. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Educational, social and recreational activities are being scheduled although staff ratios may occasionally be insufficient to meet the needs of people living in the home. A varied programme of social and recreational activities are scheduled that may be restricted due to access to appropriate transport. Contact with family and friends is encouraged and supported. People living at the home are supported to make choices about their daily lives. The home is monitoring the dietary intake of people living there providing the opportunity for a healthy and nutritional diet. EVIDENCE: Activity schedules are developed with the people living at the home when they move in and reflect their interests and needs identified in the placing authority care plans. People living at the home indicated that they have regular trips out including swimming, bowling and skittles. One person is looking forward to Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 13 resuming an evening course at a local college. College courses and other day activities are being explored. Some people like to go to social clubs in the evenings. One person said they receive therapeutic earnings for a gardening job and for collecting the post each day. On the day of the inspection people living at the home had the opportunity to go bowling in the morning and shopping at a local village in the afternoon. Those who chose to stay at home either spent time in their rooms listening to music or were supported by staff playing games or watching television. One person said they were looking forward to a trip to the pub the following day. Staff confirmed that day trips are occasionally arranged to places such as Drayton Manor and West Midlands Safari Park. Some staff indicated that trips out can be ‘challenging’ due to staffing ratios. (See Standard 33) The home presently has the use of a transit vehicle whilst the home’s 14seater vehicle is in the garage. There are only two members of staff, including the registered manager, who are able to drive this vehicle (and the home’s usual vehicle). The home also has a saloon vehicle which other staff are able to drive. Some people like to walk to the local village or use local buses. The registered person must review the current transport systems to ensure that people living at the home have regular access to a range of daytime and evening activities. This review of transport arrangements will be assessed at the next inspection. Comment cards received from relatives indicated that they are made to feel welcome when visiting and are able to meet in private if they wish. Several people living at the home go home for weekends and transport is provided where necessary. One person indicated that he likes accompanying a person when they go home to Bristol. People living at the home were observed being treated with dignity and respect. During the inspection they chose whether to spend time with staff in the communal areas or to spend time in their rooms. Staff were on hand to provide support where needed. Rules on smoking, alcohol and drugs are discussed with people living at the home as indicated in the Service User Guide. The menu is drawn up at house meetings and represents favourite meals of the people living at the home. This is a mixture of fresh and frozen ingredients. There was ample fresh fruit in the home and staff indicated that this was always provided. There was some concern about the number of ‘fast food outlets’ that had been visited in the previous week and whether this was a healthy lifestyle. This had also been discussed at a house meeting and staff are encouraging people living at the home to eat plenty of fresh vegetables and fruit. On the day of the inspection people had sandwiches or spaghetti and scrambled egg for lunch and a homemade curry and naan bread for tea. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 14 The registered person must ensure that the actual meals provided are recorded for people living at the home so that their dietary intake can be monitored. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Staff have access to information for most people enabling them to support people in the way in which they would prefer. People living at the home have access to a range of healthcare professionals making it possible to meet their physical and emotional health needs. An improvement is required in the administration of medication to ensure that the risk of making an error is minimised. EVIDENCE: The ways in which people would like to be supported are identified in their care plans. Staff indicated an awareness of these needs. Key workers and co-key workers are being appointed to support and work with people living at the home. On the day of the inspection routines were flexible and reflected the needs and wishes of people living at the home. Most were up early and ready to go out whereas the others had a more leisurely start. Daily diaries indicate that times for going to bed are flexible and that the disturbed sleep patterns of one person are being monitored. People are registered with a local GP and dentist when they move into the home. The GP has also visited the home to meet with the new residents. Referrals are being made to the local Community Learning Disability Team as necessary. Healthcare notes are kept on each individual’s file giving the Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 16 outcome of the visit. The registered manager confirmed that referrals are being made for chiropody treatment. The home uses a monitored dosage system for medication. Staff receive training in the safe handling of medication. Improvements need to be made to the system presently in use to ensure that the risk of making an error is reduced. The registered manager must: • • • • • • Ensure that handwritten entries are signed and preferably countersigned medication must be taken to the person and dispensed to them from the blister pack and original container, then the record can be signed creams and liquids must be labelled with the date of opening and disposed of in accordance with guidance of the product stock control records must be kept for PRN medication a copy of September 2005 BNF should be purchased a list of signatures and initials of people administering medication should be in place. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home has a satisfactory complaints system in place with some evidence that people living at the home feel they will be listened to. The home is protecting people living there from abuse by providing appropriate training for staff EVIDENCE: The home has a complaints policy and procedure that complies with the requirements of the Care Standards and is in a format appropriate to people living at the home. One complaint was received from a person living at the home and processed quickly and effectively. Full documentation was available. Any complaints should be recorded in a complaints log indicating the date the complaint was received, the date the investigation was completed and the outcome. People living at the home indicated that they would speak to the registered manager or group manager if they had a concern. Training is being arranged for staff in the protection of vulnerable adults. Those staff spoken to are aware of their responsibilities should they have concerns about poor practice or abuse. Staff confirmed that they attend training in managing challenging behaviour with a training provider accredited with BILD. They spoke about how they use this training to divert, diffuse or de-escalate behaviour. A policy and procedure is in place for the management of challenging behaviour and guidelines are in place for individuals. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28 and 30. The environment is homely and comfortably furnished. There is an ongoing maintenance and refurbishment programme in place making sure that the home continues to meet the needs of the people living there. EVIDENCE: Fern Court is set in large well-maintained grounds and provides stylish comfortable accommodation. People moving into the home are encouraged to decorate their rooms to reflect their interests and lifestyles. One person said they are planning to redecorate their room. Both rooms examined were personalised and fitted out with good quality fittings. People have access to a lockable drawer in their bedside units and to a key to their room. All rooms have en suite facilities. Bath and shower rooms are provided on the ground and first floors. Communal spaces were clean and tidy. Furnishings are of a good quality. People were observed making good use of the two lounges and dining room. Those spoken to indicated that they liked their new home. There are tables and chairs in the gardens. The home has a day-to-day maintenance programme in place. The following issues were identified during the inspection and must be actioned: Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 19 • • Toilet roll holders put in place in communal toilets and bathrooms Window restrictors on the first floor bathroom must be secured so that the window cannot be taken off the restrictor. The home has a domestic size laundry. Staff are supplied with personal protective equipment and infection control training is being provided. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. The staff have a good understanding of the support required by people living at the home and this is evident from the positive relationships which have been formed with staff. Current staffing levels do not always meet the needs of people living at the home occasionally putting people living at the home at risk. Recruitment and selection procedures are in place promoting the safety of people living in the home. Staff have access to a range of training, providing them with the knowledge and skills to meet the needs of people at the home. EVIDENCE: The registered manager stated that the majority of the staff group have previous experience of working with people with a learning disability. Discussions with staff confirmed their understanding and awareness of the needs of people living at the home. People living at the home indicated that they liked staff and one said that the ‘staff are very good’. The registered manager and staff stated that three members of staff are scheduled to work Monday to Friday dropping to two at weekends when some people are away. One person sleeps in overnight and there is a waking night member of staff. Placing authority care plans identify that three people living Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 21 at the home are on 1:1 staffing ratios and two people are on a 2:1 staffing ratio when accessing the community. This indicates that the home is understaffed at present when one person on a shared care contract is staying at the home. The registered person must ensure that the correct ratios of staff to service users are in place. The files of three new members of staff and one member of staff transferred from another home were examined. The latter file contained only one reference. Subsequently, the second rererence was located in the file at the previous home, also part of the organisation. Other files contain information as requested under Schedule 4 and indicated that Schedule 2 is being complied with. Staff are not being appointed without two written references and a Pova first or CRB check in place. CRB checks were sampled and can now be destroyed in line with Data Protection. The registered manager was advised that CRB checks should be kept securely and separate from staff records. A training programme is in place to provide staff with an internal induction, following Skills for Care specifications. Learning Disability Award Framework training for new staff to care is being put in place. Other staff have completed Care Practice training and some are doing NVQ’s in Care. Other mandatory training is either in place or being scheduled. Training specific to the needs of people living at the home is being organised including management of challenging behaviour, autism and learning disability and sexuality. A training database is being maintained and each member of staff has their own training record with copies of certificates. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. The registered manager has a clear developmental plan for the home. A quality assurance system needs to be introduced to enable people living at the home to monitor and review the service being provided. Systems are in place ensuring that the home provides an environment promoting the welfare and safety of people. EVIDENCE: The registered manager has just completed a Registered Managers Award at Level 4. He has considerable experience in the field of learning disability. He has put a range of policies and procedures in place for the home and will be making sure that these are being implemented. A current certificate of insurance is in place and the home’s registration certificate is displayed. The registered manager recognised that an error had been made in permitting a person into the home without evidence of a learning disability and is taking steps to rectify this. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 23 The home has regular unannounced visits from senior management and copies of these reports are forwarded to the Commission under Regulation 26. There was no evidence of other quality assurance systems in place yet. These will be examined at future inspections. Health and safety systems are in place for the monitoring of fire systems on a regular basis. Fridge and freezer temperatures are being recorded. Correct procedures are being followed for food stored in fridges and freezers. Temperatures are being taken for cooked meat. It is recommended that these be recorded. A plumber is testing water temperatures but the registered manager was unsure how often this was being completed. He should ensure that each month a sample of outlets is tested. Portable appliance testing is in place. The accident and injury book is being completed correctly and records stored securely. Staff are completing training in Fire, Moving and handling and Infection Control. Basic Food Hygiene and First Aid training are outstanding for some staff. There was evidence that this has been arranged. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 3 3 X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fern Court Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000062152.V249410.R02.S.doc Version 5.0 Page 25 N/A 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 2 Standard YA1 YA6 Regulation CSA Section 24 Requirement Timescale for action 22/09/05 3 4 YA9 YA13 5 6 YA17 YA24 7 YA33 8 YA39 The home must operate within its category and conditions of registration 15(1)(2) All service users must have a care plan in place and they must be reviewed/amended when changes in need occur. 13(4) Risk assessments must be put in place as indicated in the text. 16(2)(m)(n) Service users must have access to regular activities and appropriate transport to enable them to achieve this. 17(2) A record of all meals provided Sch.4.13 for service users must be kept. 23(2)(c) Toilet roll holders must be placed in communal bathrooms and toilets. Window restrictors on the first floor bathroom window must be secured. 18(1)(a) Staffing levels must be appropriate to the needs of service users as identified in the contracts with their placing authority. 24 A quality assurance system must be put in place for the home involving feedback from service users. DS0000062152.V249410.R02.S.doc 14/10/05 14/10/05 31/12/05 14/10/05 14/10/05 14/10/05 31/12/05 Fern Court Version 5.0 Page 26 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 6 7 Refer to Standard YA2 YA2 YA20 YA22 YA34 YA42 YA42 Good Practice Recommendations An assessment tool should be used by the home for all prospective service users. A record should be kept of visits to the home prior to admission. Two signatories should countersign handwritten entries on the medication assessment record. A complaints log should be kept. CRB checks should be kept securely and separately from staff files. Cooked meat temperatures should be recorded. Water temperatures from outlets around the home should be sampled each month. Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Fern Court DS0000062152.V249410.R02.S.doc Version 5.0 Page 28 - 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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