Inspection on 14/11/05 for Ferndene Care Home

This inspection was carried out on 14th November 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ferndene Care Home 19/11/07

Ferndene Care Home 06/02/07

Ferndene Care Home 03/04/06

Ferndene Care Home 06/06/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Fern Dene Care Home Francis Chichester Walk Park Springs Road Gainsborough Lincolnshire DN21 1NR Lead Inspector Mr Doug Tunmore Unannounced Inspection 14th November 2005 09:00 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 Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fern Dene Care Home Address Francis Chichester Walk Park Springs Road Gainsborough Lincolnshire DN21 1NR 01427 810 700 01427 810 600 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) Executive Care Management Care Home 48 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (48), Old age, not falling within any other of places category (48) Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories; Older people, Old age not falling within any other category OP (48) Dementia, over sixty-five years of age DE (E) (48) Dementia over fifty years of age (5) Maximum number of service users to be accommodated is 48. 2. 3. 4. Date of last inspection 6th June 2005 Brief Description of the Service: Ferndene Care Home is situated in Gainsborough some twenty miles north west of Lincoln, 20 miles south of Scunthorpe and 15 miles south east of Doncaster. It is a purpose built two-storey care home in its own landscaped grounds. There are shops, a public house, a primary school and other local community amenities near by. The home is on a local bus route and is within easy 5 minutes travel of the centre of Gainsborough. Ferndene Care Home is newly built, completed in March 2005. The home caters for both male and female residents; there are 19 ground floor and 29 first floor bedrooms, which are accessed by an eight- passenger lift, which is code lock protected on the first floor. All bedrooms are en-suite and exceed the Care Standards size requirements. All bedrooms have TV and telephone points fitted and are fully equipped and decorated. There is a large Entrance Hall and Reception Foyer, which includes a coffee shop for the residents and a fully equipped hairdressing salon. The ground floor accommodates a large fully equipped modern kitchen. The first floor, which is accessed by code locks accommodates a dining area, and two lounges. The home has a loop system for the hearing impaired, grab rails fitted, a call system fitted and ramps for wheelchair users. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.00 am. The main method of inspection used was called case tracking, which involved selecting two residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observations of care practice. The manager, staff and residents were very open to the inspection. A partial tour of the premises took place. What the service does well: What has improved since the last inspection? What they could do better: There was no evidence found in this inspection that the following procedures or practices have been undertaken: 1. There was no evidence of residents’ involvement in the development of, or agreement with, care plans, care admission assessments or risk assessments. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 6 2. The home was found not to have a policy of giving personal care to residents and care plans did not reflect how individual residents personal care needs were to be met. 3. The dietary needs of residents do not include which drinks they prefer. 4. A comment was received that a teatime meal was served cold and no jam was available. 5. There was little or no evidence that new staff have undertaken in house training (induction). 6. There is no evidence that new staff have undertaken National Training for Social Care (TOPSS). 7. The homes training file is not up to date. 8. Monies belong to a resident has not been forwarded to them when they left the home. 9. Receipts are not kept showing what monies residents have spent. 10. There was no evidence that a hoist and shaft lift had been serviced within the last six months. 11. There was no evidence that that the home has a fire risk assessment. 12. There was no evidence that emergency lighting had been tested and would activate in the event of a fire at night. 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 Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected on this occasion. EVIDENCE: Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 9 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 & 10 Progress is being made in improving care plans to ensure that the general health and welfare of residents is addressed. Neither residents nor their representatives undertake the signing of care plans. Care plans do not reflect the intimate care needs of resident. EVIDENCE: All residents care plans are being reviewed and those seen describe the health and welfare needs of residents. Care plans and risk assessments did not evidence the involvement of residents and, or their relatives and were not signed by the resident or their relative. Residents confirmed that they had not seen their care plans to sign them. All residents seen commented that the home met their needs and that ‘ they are wonderful (the staff) and nothing is to much trouble’. A visitor also stated that she felt her husband was very well looked after. Files seen confirmed that health care professionals visit the home when required by the residents. One carer stated that she was aware of the personal care needs of residents. Care staff were seen to be both polite and treated residents with respect on the day of the inspection. One resident Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 10 commented that ‘ care staff wash me and I have every confidence in them’. A visitor said that she visits her husband regularly and that ‘staff are very caring and look after him very well, he always looks lovely and they attend to his personal care’. The home was found not to have a policy on giving personal care to residents and care plans did not reflect how individual residents intimate care needs were to be met. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 11 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 & 15 The home provides a range of activities and leisure interests both within the home and community. These are based on residents preferences who are encouraged to make choices about their preferred lifestyles and routines. EVIDENCE: The home has an activities organiser who works twenty hours a week. She was seen and evidenced from her activities book and the ‘Dates For Your Diary Programme’, which is posted on the notice board that a wide range of activities are undertaken. Residents spoken to during the inspection said that they are able to take part in a variety of activities and leisure interests, including trips to the shops, visits to their own home, bulb planting, quizzes, bingo, Halloween decorations, pie and pea suppers, remembrance service, winter fair, and the planned family Christmas party. Residents also said that they have the choice of whether and what they participate in. One resident said that she is known as the ‘bingo queen’. A relative stated that she attends the home regularly and is always made welcome. She has also said that she has seen activities taking place and attended the pie and pea supper. Residents confirmed that relatives visit them and that they can see them in their rooms if they wish. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 12 Staff said that church services are held for residents who wish to take part in this activity. The inspector joined two residents for lunch and found the meal provided to be hot and delicious. Residents said that they have a choice of meals and they look forward to meal times. A visitor commented that she found the teacakes at one teatime meal to be cold and there was no jam available to residents. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 13 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): The above standards were not inspected on this occasion. EVIDENCE: Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 14 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): The above standards were not inspected on this occasion. EVIDENCE: Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 15 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): 30 Staff are not trained to carryout their jobs. EVIDENCE: None of the care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen and found not to be up to date. The acting manager confirmed that the training file is not up to date. A care worker said that she had not undertaken initial training when she commenced work at this home and had not undertaken TOPSS training relating to the care of the elderly. No evidence was seen that the home carries out training for new members of staff. However, the care worker stated that she has undertaken health and safety training, fire training, basic food hygiene and infection control. The homes diary showed that planned training for moving and handling is planned for January 2006. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 16 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): 31,32, 35, 36 & 38 The acting manager ensures that the home is managed for and with the residents. Appropriate checks are not carried out to ensure the safety of residents. Resident’s financial interests are not safeguarded. Improvements have been made in the supervision of care staff. EVIDENCE: The acting manager has fourteen years experience in working in various settings with differing client groups. She has qualifications in management, which include supervising management and a management diploma. She has also undertaken a course at the Open University on Patterns for Living. A care worker stated that the manager has an open door approach to both residents and staff who require support and guidance. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 17 The acting manager has applied to the Commission for an application to undertake a ‘Fit Person’ interview. Due to this no requirement will be made regarding her acting status. Residents confirmed that they can talk to the manager about their lives and she is always helpful and fair. One said that she joins in with some activities. The home only deals with personal allowances of residents, which are kept at the home. All other monies relating to funding are paid into the company who owns the homes bank account on a standing order, direct debit or by check by relatives or the County Council. Residents personal allowances were seen and it was found that an accurate record is kept. However, monies were still kept by the home of a resident who had left the home on the 31/08/05. It was also found that receipts are not kept of all payments for personal items or services that the residents might require. A visitor commented that she and her son dealt with her husband’s finance. There are a range of policies and procedures available to the manager and care staff for the protection of residents and staff. However, there was no evidence that the following checks had been undertaken; hoists and shaft lift had been serviced within the last six months, that that the home has a fire risk assessment, that emergency lighting had been tested and would activate in the event of a fire at night. All wheelchairs seen on the day of the inspection had footplates, which were in use. Window restrictors were in place and were seen to be fixed, safeguarding residents. Supervision of all care staff is not undertaken on a regular basis. Care workers files showed that supervision has been undertaken on six care workers. One carer confirmed that she had supervision undertaken by the care manager. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 2 2 x 2 Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The home must ensure that consultation with residents and relatives is undertaken and that care plans and risk assessments are signed to confirmed agreement on the care to be delivered. The home must ensure that a policy/guidelines on giving personal care to residents is made available to care workers and is part of their induction. The home must ensure that care plans reflect how individual residents intimate care needs are to be met. The home must ensure that all meals are served hot and that jams and other accruements are made available. The home must ensure that likes and dislikes include those drinks that residents prefer. The home must ensure that the persons employed by the registered person to work at the care home receive- training DS0000061520.V265585.R01.S.doc Timescale for action 15/01/06 2 OP10 12(4)(a) 15/01/06 3 OP10 12(3) 15/01/06 4 OP15 16 15/01/06 5 6 OP15 OP30 16 18(c )(i) 15/01/06 15/01/06 Fern Dene Care Home Version 5.0 Page 20 7 8 OP30 OP35 18(c) 17(2) 9 OP36 18 10 11 12 OP38 OP38 OP38 23(4)(v) 23(2)(n) 23(4) appropriate to the work they are to perform. The home must provide up to date evidence that all care staff undertake training. The home must ensure that residents monies are made available to them and that receipts are kept to show what monies residents have spent. Members of staff are to be in receipt of regular supervision; minimum six times per year. It is acknowledged that efforts have been made by the acting manager to address this standard. (Timescale of 31/07/05 not met) The home must undertake monthly checks of the homes emergency lighting. The home must provide evidence that hoists and shaft lift are serviced on a six monthly basis. The home must produce a fire risk assessment and seek advice from the Fire & Rescue Service to ensure that the document meets their standards. 15/01/06 15/01/06 15/01/06 15/01/06 15/01/06 15/01/06 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 OP30 Good Practice Recommendations The home should furnish all staff with the General Social Care Councils Conduct of Practice for their information. Fern Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Dene Care Home DS0000061520.V265585.R01.S.doc Version 5.0 Page 22 - 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. 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