Inspection on 24/01/07 for Fern Croft

This inspection was carried out on 24th January 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fern Croft 01/11/05

Fern Croft 31/05/05

Fern Croft 10/12/04

Fern Croft 20/04/04

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 Croft Ferncroft 14 Heathville Road Gloucester GL1 3DS Lead Inspector Lynne Bennett Key Unannounced Inspection 24th January 2007 10:00 Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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 Croft DS0000048719.V318771.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 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 Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fern Croft Address Ferncroft 14 Heathville Road Gloucester GL1 3DS 01452 505803 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 To be appointed Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Fern Croft is a residential care home registered for seven adults with a learning disability in the Kingsholm area of Gloucester. The home specialises in supporting people who may present behaviours that challenge the service. The home is owned by New Beginnings (Gloucester) Ltd and part of a group of three homes, first established in Gloucester in 2002. Fern Croft, which opened in January 2004, provides single en suite accommodation for six people and a second floor bed sit for one person. Residents have access to a comfortable lounge, a dining room and domestic size kitchen. To the rear are spacious gardens laid mainly to lawn with a patio area. Each person has a copy of the Statement of Purpose and Service User Guide. Copies are also available from the office. The fees for the home range from £1275 to £1750 per week. Additional charges are payable for toiletries. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in January 2007 and involved two visits to the home on 24th and 25th January. The group manager was in attendance for some of the time. Four people living at the home were spoken to and their care was observed. Discussions with staff centred on the care provided in the home. A pre-inspection questionnaire was returned prior to the inspection commencing with additional information about training, rotas and meals. One service user comment card was returned and two comment cards from relatives were received. Additional records examined during the inspection included service users care plans, staff files and health and safety records. Medication administration systems were also inspected. What the service does well: What has improved since the last inspection? A fly screen has been installed to the window in the kitchen meeting with requirements issued by Environmental Health. Plans have been passed to build a conservatory in the garden to increase the amount of communal space available to people. Fern Croft DS0000048719.V318771.R01.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. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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 Croft DS0000048719.V318771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. By reviewing the Statement of Purpose and Service User Guide the home will ensure that people have up to date information about the service they are to receive. People wishing to move into the home do so with the confidence that their needs and wishes are assessed. EVIDENCE: The Statement of Purpose and Service User Guide will need to be reviewed in light of changes within the organisation. Each person living at the home has a personal copy and people wishing to move into the home are sent copies as part of the pre-admission information. The home presently has three vacancies. A recent admission to the home was fully assessed by their placing authority. Copies of this assessment and care plans were provided to the home prior to making a decision about whether their needs could be met. Additional information was also supplied from their previous placement. The group manager explained that a new assessment is being used by New Beginnings for future admissions to the home that will complement other information obtained. There was evidence that people are Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 9 invited for visits to the home. Records of these stays are kept as part of the initial assessment process. This is good practice. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning in the home is generally good promoting the development of skills and independence. Risk assessments encourage and support people living at the home to challenge and deal with problem areas in their lives. Improvements in developing records for new people moving into the home will ensure that staff are provided with the information they need to satisfactorily meet their needs. People are provided with support to make decisions and choices about their day-to-day lives. EVIDENCE: The care for two people was case tracked and files sampled for the other two people living at the home. Each person has a main file that contains copies of their care plans and risk assessments. Care plans indicate when risk assessments are needed and there was evidence that these are in place. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 11 These records are being reviewed each month and any changes or comments recorded where appropriate. Each person also has a bound monthly diary that contains their daily records, behaviour management charts and any other monitoring forms that are relevant to them. This is an excellent way of keeping information together. The person who had recently moved into the home had one care plan in place for oral hygiene and a full range of risk assessments. Staff indicated that there had been discussion about other care plans but were unable to locate these. For instance there was evidence that this person enters other peoples’ rooms without their permission. Staff described the action that had been taken to minimise this. Care plans need to be developed in line with the assessment on their file. They also need to record any restrictions or limitations on facilities such as the use of a door alarm on their bedroom door. There was evidence that people are having annual reviews with their placing authority and copies of these reviews are being provided to the home. Some care managers have signed care plans and risk assessments. The group manager confirmed that people who move into the home have a three-month placement review. Staff spoken with have a good understanding of the needs of the people they support. They were observed enabling them to make choices about their activities of daily living. One person asked to go out for a cake and was supported to do this in the afternoon. Another person was consulted about their lunch. One person is being referred to a local advocacy group for access to an advocate. This was suggested at their last review and has been followed through by the home. Most people need support to manage their finances. Discussions with the group manager confirmed that financial risk assessments must be put in place. Staff need guidance about correct procedures for use of personal debit cards and supporting people to go to the bank. Financial records were examined. Receipts are cross-referenced with debits and credits. Some people have savings accounts. Each person has a missing person’s procedure in place with relevant information and a photograph. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have access to a range of local community facilities and activities providing opportunities for them to be involved in their local community and lead active lifestyles. Independence and choice are promoted by staff enabling people living at the home to participate in activities of daily living. Relationships with family and friends are developed and maintained with the help of staff. People living at the home are supported to maintain a healthy lifestyle with access to freshly cooked meals. EVIDENCE: Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 13 Each person has an individual activity schedule that has been produced in a mixture of text and symbol. These are displayed on a notice board. During the visits people were supported to go into town, to go shopping, to a café, and to go to college. One person was looking forward to going for a cake at a café in town and another said they enjoyed going to college to do an art course. People also had appointments for a massage at the home. One person said they liked having this done. Any activities are recorded in the daily diaries providing additional evidence that people have access to their scheduled activities. People also go to a local leisure centre for swimming and to use the sauna or steam room as well as to the cinema and social clubs. One person said they enjoy going to ‘ball skills’ at a local sports club where they play tennis, football and basketball. People were observed spending time in the lounge colouring, playing a keyboard or listening to music in their rooms. Staff positively interacted with people during the visits spending time with them in the lounge or their rooms if appropriate. One person said they have music lessons each week. Whilst at home people have scheduled household tasks to complete. One person was observed helping to put dishes into the dishwasher. Other jobs include helping to clean their rooms and communal areas. Daily diaries indicate contact kept with family and friends. People said that this is done over the telephone and by visiting. One relative commented “we are very pleased with the care and the staff who accompany my relative on visits”. Menus are produced on a four-week basis. Different menus are in place in winter and summer. People are involved in helping to devise the menus. Alternatives are available to the scheduled meal. Records are kept in each person’s daily diary. There was evidence of fresh produce during the visits. Good practice is followed in the kitchen ensuring that any opened food is labelled with the date of opening. Concerns were expressed during the visits about the budgets for provisions. Accounts were examined for three months which indicated that the provisions budget was overspent on three occasions but under spent during the rest of the period. There appeared to be some discrepancies in recording of meals eaten out with staff recording these under the activities budget. This would indicate that the provisions budget is not sufficient. This needs to be reviewed. At the time of the visits there appeared to be sufficient food in the cupboards, freezer and fridge. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The healthcare needs of people living at the home are well met with evidence of multi disciplinary support on a regular basis. People living at the home have access to a range of healthcare professionals making it possible to meet their physical and emotional health needs. Systems for the administration of medication safeguard people from possible harm. EVIDENCE: People have a pen picture that describes how they would like to be supported with their personal care needs. One person said that they prefer the support from male staff. The rota indicated that wherever possible a male member of staff is available on each shift. Staff were observed treating people with sensitivity and respect. People have support from members of a Community Learning Disability Team. Communication profiles are in place for those people who need them. There was lots of evidence of the use of symbol and photographs around the home. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 15 One person uses a Picture Exchange Communication System (PECS) and tools to use were available in the dining room. Staff indicated that the person will communicate verbally and does not like to use the tools available. Reports from their Speech and Language Therapist indicate that despite this it is important that the system is used with the person to improve their vocabulary and reinforce their verbal communication. Staff are recommended to support the person to use this system on a regular basis. People have regular access to a range of healthcare professionals. Records confirmed that new people are registered with a Doctor although there was no evidence that they had been registered with a Dentist. A member of staff indicated that this would be done. Staff confirmed that where there are concerns about the health and wellbeing of people they are referred to the appropriate healthcare professionals. Records on file confirmed this. A range of monitoring charts are in place which staff complete on a daily basis. Body charts are also used to monitor bruises or marks. Staff have access to a range of information about people’s individual conditions including a monthly magazine. Discussions with them confirmed a good understanding of the people they support. Medication systems were examined. Staff confirmed that they receive training in the safe handling of medication. A signature list of staff able to dispense medication is in place. One staff member is waiting to complete training and dispenses medication alongside another member of staff. Records are in place to confirm this. Good practice was observed to be in place. Any handwritten entries on the medication administration chart need to be signed by the author and if possible countersigned by another member of staff. It is also advised that a system should be put in place to monitor the knowledge and practice of staff administering medication. The medication cupboard is a stand free cabinet this must be fixed to the wall in line with The Royal Pharmaceutical Society’s guide to ‘the administration and control of medicines in care homes’. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their views will be listened to and acted upon. Systems and procedures are in place for the protection of people living in the home safeguarding them from possible harm. EVIDENCE: The home has a complaints policy and procedure which is produced in a format appropriate to the needs of people living at the home. A copy of this is displayed in the hall. The home has received one complaint since the last inspection which was dealt with to the satisfaction of the complainant. Staff said that they have attended training in the protection of vulnerable adults and discussions confirmed their understanding of possible causes of abuse. Behaviour management plans and reactive strategies provide staff with guidance about the support needed by people who may present with challenges. Behaviour monitoring forms are maintained. Staff confirmed that they attend training in the management of challenging behaviour. Discussions with them indicated that they have a good understanding of diversion and diffusion tactics. Staff said that they do not use physical intervention. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 17 Staff and the group manager confirmed that where there are concerns about the behaviour of people living at the home these are referred to healthcare professionals for their support and advice. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely and comfortably furnished. Improvements to the maintenance programme will make sure that the home continues to meet the needs of the people living there. Safe practices ensure that a clean and hygienic environment is maintained. EVIDENCE: Ferncroft provides pleasant accommodation which is regularly decorated and has day to day maintenance systems in place. Some concerns were expressed about the response of the maintenance team to some minor repairs, such as locks to wardrobes. Staff said that they log maintenance issues which are then prioritised by the team for action. The group manager needs to monitor this through Regulation 26 visits. Maintenance work was being completed during the visits. The group manager confirmed that the team would be completely redecorating the top floor accommodation. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 19 A conservatory is scheduled to be erected in the rear garden which will increase access to communal accommodation to people living at the home. People were observed spending time in the lounge which has three comfortable sofas. The dining room has been painted and adorned with pictures since the last inspection. People have personalised their rooms to reflect their personalities and lifestyles. There has been a problem with one person going into other people’s rooms. One person asks staff to lock their room when they are out. It was suggested that another person may wish to have their room locked and staff agreed to discuss this with them. One person does not like to have curtains in their room. A covering needs to be put on the window to provide some privacy. At the time of the inspection the home was clean and tidy. Hazardous products are stored securely and COSHH data sheets are available. Personal protective equipment is available should it be needed. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have the skills and knowledge to support people living at the home ensuring that their needs are met. Robust recruitment and selection procedures will protect people living at the home from possible harm. Access to training is improving, providing staff with the qualifications, skills and experience they need to support people living at the home. EVIDENCE: The organisation has a NVQ programme in place. Staff are offered Learning Disability Award Framework (LDAF) induction to complement the home’s induction programme. From this they then proceed onto NVQ Level 2 in Care. Certificates are kept on their personal files. One staff member confirmed they have completed their Level 3 Award and are thinking about registering for a Level 4 Award in Care. A training matrix confirmed that all staff either have a NVQ Award or are completing LDAF Awards. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 21 There was evidence that some staff despite being in post for almost four months have not completed their induction programme with the home. This should be monitored. Files were examined for three new members of staff. Each person has an application form with a full employment history. There was evidence that where this was not supplied this information is obtained at interview. This form has been changed and omits to ask people why they left their former positions in care. This should be included. One person is still waiting for the return of a Criminal Records Bureau (CRB) check. A povafirst check is in place. Although this person and staff described the restrictions which are in place until the CRB check is received there is no formal risk assessment. This must be put in place. All CRB checks can now be destroyed. There was evidence that two references have been obtained prior to starting work although in one instance three personal references had been obtained and no employment reference. This must be obtained. There was also no evidence that checks had been made with former employers about why people had left those positions. An occupational health assessment is completed. A robust training programme is in place. Staff confirmed that they have access to mandatory training and training specific to the needs of people they support such as mental health, communication and autism. The group manager explained that new training providers have been sourced to ensure that training is maintained. Copies of certificates are kept on individual’s files. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The appointment of a manager will provide stability and leadership to the home. The home’s quality assurance programme involves people living at the home in the review of services being provided. An improvement in the systems being used will make sure that the home provides an environment promoting the welfare and safety of people. EVIDENCE: Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 23 The registered manager recently resigned from the home. The group manager confirmed that a new manager has been appointed and will be applying to the Commission to become registered. The previous manager had worked hard to ensure that standards within the home were significantly improved and it was evident that staff are confident with the systems that are in place to maintain these standards of care. A quality assurance system is in place which involves people living at the home. Surveys have been conducted with people, their relatives and other healthcare professionals involved in their care. A report is being produced as a result of this audit. In addition monthly unannounced visits are conducted and reports compiled. The group manager said that New Beginnings are discussing with Investors in People to be assessed for their award. Health and safety systems are in place for the monitoring of fire, water temperatures and servicing of equipment. Fridges and freezers are monitored on a daily basis although recent records indicate that the fridge in the kitchen is recorded as over 10 Centigrade. This needs further monitoring to make sure that the fridge is not operating outside safe parameters. It is suggested that the safe parameters are indicated on the recording forms and any action taken as a result of high readings are recorded. Portable appliance testing was due to be completed in November 2006 and the group manager confirmed that this had been done although there was no evidence in the home. He agreed to supply this after the inspection. Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X 2 2 X 2 X 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 3 X Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 25 No 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 YA6 Regulation 15(1) Requirement People who move into the home must have a care plan developed from their assessment as to how their needs are going to be met. People who use services must be aware of any limitations to their freedom or choices. Financial risk assessments must be in place to provide staff with guidance about how they can safeguard people’s personal monies and valuables. When medication is recorded on the administration record staff must sign to indicate this is correct. The medication cabinet must be fixed to a wall ensuring that it is secure. The privacy of people must be respected by providing a suitable alternative to curtains at their bedroom window. Records must be obtained prior to the appointment of staff to make sure that they are fit to work in the home. The manager must apply to the Commission to become registered. DS0000048719.V318771.R01.S.doc Timescale for action 28/02/07 2. 3. YA6 YA9 17(1)(a) 13(6) 28/02/07 31/03/07 4. YA20 13(2) 28/02/07 5. 6. YA20 YA24 13(2) 16(2)(c) 28/02/07 28/02/07 7. YA34 19(4)(b) Schedule 2 9(2) 28/02/07 8. YA39 30/04/07 Fern Croft Version 5.2 Page 26 9. YA42 13(3) Fridges which are operating outside safe parameters must be made safe to prevent the risk of infection to people at the home. 31/03/07 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. Refer to Standard YA18 YA17 YA20 Good Practice Recommendations Staff should use the PECS approach to communication as recommended by the Speech and Language Therapist. The provisions budget should be reviewed to ensure that there are sufficient funds available for peoples’ dietary needs. Staff should countersign any handwritten entries on the medication administration record. An audit should be introduced to monitor the knowledge and practice of staff dispensing medication. Ensure that any minor repairs such as locks to wardrobes are actioned. Monitor outstanding maintenance issues as part of the Regulation 26 visits. Offer keys to people for their rooms or make alternative arrangements to ensure rooms are secure. Monitor induction training to ensure that it is completed. Application forms for new staff should request them to supply the reason for leaving former positions in care. Monitoring records for fridges should indicate safe parameters and action taken to make fridges safe. 4. YA24 5. 6. 7. YA32 YA34 YA42 Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Fern Croft DS0000048719.V318771.R01.S.doc Version 5.2 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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