Inspection on 03/04/06 for Ferndene Care Home

This inspection was carried out on 3rd April 2006.

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 14/11/05

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 3rd April 2006 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.V287919.R01.S.doc Version 5.1 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.V287919.R01.S.doc Version 5.1 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.V287919.R01.S.doc Version 5.1 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 14th November 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.V287919.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection. 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, discussions with residents, the care staff and observations of care practice. The acting manager was on annual leave at the time of this 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) Pre-admission care assessments are not undertaken by the home prior to prospective residents being admitted to the home. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 Page 6 2) Residents are not written to by the home confirming that the home can meet their care needs. 3) Monthly reviews of residents care needs are not recorded. 4) Medication is not given to residents when required. 5) The home has not introduced a intimate care policy. 6) Files contained limited information of residents dietary requirements. No written information was available to the cook on duty regarding residents dietary requirements. 7) The homes complaints file did not contained documentation for the processing of complaints. 8) No safeguarding vulnerable adults training has been undertaken. 9) Documentation relating to the maintenance of the home was not available. 10) There was no evidence that a quality assurance monitoring system is undertaken in the home. 11) Appraisals and supervision of staff is not undertaken. 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.V287919.R01.S.doc Version 5.1 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.V287919.R01.S.doc Version 5.1 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): 3 The home has not fully assessed the needs of residents prior to their admission to the home. The home has not written to prospective residents to confirm that the home can meet their needs. EVIDENCE: Two residents confirmed that they had not been visited by someone from the home prior to admission nor had they received a letter to their knowledge confirming that the home could meet their needs. Both residents said that they had a pre-admission visit to the home, either accompanied by a family member or a social worker. Files seen did not contain copies of letters sent to prospective residents nor could evidence be found that the home assessed residents care needs prior to admission. Both files contained a social workers assessment of need. One care worker knew about the care needs of residents and explained that she has no input into the homes assessment process. A third file seen showed that a resident had been admitted as an emergency admission. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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): 7,8,9 & 10 Not all files showed that monthly reviews had been undertaken. Accidents are recorded as per the homes policies. Medication is not always administered correctly. The home has not introduced an intimate care policy. EVIDENCE: It was noted that a senior care worker giving medication informed residents what medication they were being given and what it was for. This is an example of very good practice. Medication sheets were seen and showed that medication given on that day had been signed for correctly. However, one resident spoken to said that she had not had her eye ointment on the previous day. A check of her medication sheet showed that she had only been given her eye drops five days out of ten days. The medication had not been given as it could not on occasion be found a quick search discovered the eye drops in the medicines fridge. The senior carer said that she would discuss this oversight with the night care staff. The pharmacist carried out an inspection on the 13/02/06 the report showed that administration records were good and storage and stock control was good. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 Page 10 A number of care workers are undertaking a twelve week distance learning medication course with Newcastle College. The care plans of one resident who was being case tracked were seen and found to have been signed confirming that he agreed with the care provided by the home. However, the homes policy of undertaking monthly reviews of residents care had not been undertaken with the last review being on the 01/11/05. Individual care plans evidenced that accidents are recorded in the homes’ accident book, daily notes and body maps where appropriate. The home also informs the Commission in writing about accidents to residents. 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. Two residents confirmed that they see the GP and one said that she goes to the hospital on Fridays for physiotherapy. A district nurse was contacted who commented that communication with the home is poor and within the home between carers. She also said that carers are out of their depth and lack basic knowledge. Residents made comment that ‘ care staff help us when we have a bath and tell us what they are going to do’. Another resident said that ‘carers respect what you want and I want my privacy’. The home has not written a policy on giving personal care to residents, which was a requirement at the last inspection. Care plans seen reflected that residents dignity and independence must be maintained at all times. The deputy manager commented that she had not undertaken intimate care training and that she was not aware that there is a policy in the home. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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, 14 & 15 The home provides a range of activities and leisure interests both within the home and community. Residents are encouraged to maintain contact with their families and friends. Positive comments were made about the food provided at this home. EVIDENCE: The home has an activities organiser who works twenty hours a week and also attends weekend functions. She was seen at the last inspection of this home and during this inspection. The activities organiser continues to provide a programme of activities for residents based on their requests and needs. She was able to evidenced from her activities book that a wide range of activities are undertaken. Residents spoken to confirmed that they are able to take part in a variety of activities and leisure interests. Activities include visits to their own home, bulb planting, quizzes, bingo, Easter services and monthly communion. A senior carer said that the home has a good relationship with the local school who have a stall in the homes grounds at the summer fayre. Residents from the home also visit the school for Christmas carols and nativity plays. Residents also said that they have the choice of whether they participate in activities. One file seen showed that a resident is to be encouraged to take part in activities of her choice if she so wishes. Residents confirmed that relatives visit them and that they can see them in their rooms if Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 Page 12 they wish. Another resident said that her daughter takes her home when she visits. The inspector joined three 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. Residents meetings are used to discuss the homes menus and times of when the tea trolley or meals are served. Residents files did not give enough information regarding dietary needs or likes and dislikes of residents. The kitchen was visited and it was found that there was no written information regarding residents dietary needs. One resident said that ‘I’m a diabetic and should have sugar free food, we get a lot of sweet stuff which is no good for me’. She also felt that she was not provided with sugar free cakes or puddings. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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): 16 & 18 The homes complaints folder did not evidence the outcomes of a complaint. Care staff have not undertaken safeguarding vulnerable adults training. EVIDENCE: The homes complaints file was seen and found not to contain this organisations complaints record, which should evidence the process and outcome of any complaint investigated. The home has a complaints policy and complaints information is available in the entrance lounge to the home. The deputy manager was unable to find any information relating the homes complaints format. The regional operations manager was contacted and she confirmed that a complaints file should be available with the appropriate documentation for the processing of complaints. The home has Lincolnshire’s Adult protection procedures as well as the homes whistle blowing policy. The deputy manager and senior carers as well as care staff on duty confirmed that they had not undertaken safeguarding vulnerable adults training. However, one carer stated that she would report any abuse to a resident to the manager. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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): 19 & 26 The home is well maintained, the standard of the environment and its facilities are appropriate and safe for the needs of residents. The home is clean and tidy, with a pleasant smell throughout. EVIDENCE: The home has a maintenance programme, which is kept by the handyman and relates to those fixtures and fittings, which needs replacing. However, the home does not have a rolling maintenance programme showing forthcoming maintenance and decoration to be carried out externally and internally at the home. A tour of the environment found that the home was decorated to a good standard. The home employs one cleaner with another who starts work within the next week. The partial tour of the home by the inspector found it to be clean and it smelt fresh. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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): 27, 29 & 30 There are sufficient staff to care for the residents. Staff training is now in place and all carers undertake an induction when starting at the home. The home does not carry out a thorough staff recruitment process. EVIDENCE: Of the two care workers personnel files that were seen one did not have a current photograph and the other did not have an identification of that worker. Both workers had two references and Criminal Record Bureau checks. The home has The General Social Care Council Codes of Practice, which sets out responsibilities as care workers looking after vulnerable adults. The homes training plan was seen and found not to be up to date. The training record in part identified those workers, who had undertaken statutory training in 2004 and 2005. Two care workers have NVQ (National Vocational Qualifications level 2, One is undertaking NVQ level 3 and sixteen staff have started NVQ level 2. A carer stated that she has worked in the home for three months and She has started the homes induction training programme and also confirmed that she is undertaking NVQ training level two. The homes rota was seen and it was found that adequate staffing levels are maintained to meet the needs of residents. One carer stated that there are always enough staff on duty to cover shifts. There is three waking night staff one of which is a senior carer. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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): 31,33,35, 36 & 38 Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to attend residents meetings. Quality assurance audits of residents and visitors views are not carried out. Accurate records are kept of residents’ monies. The current management structure will not be in place in the near future. EVIDENCE: During the inspection the deputy manager informed the Commission verbally that the acting manager would be leaving this home in June 2006. The regional operations manager confirmed that the acting manager was leaving and would be writing to the Commission regarding the companies plans for a replacement manager. There was no evidence available to show that the home conducts, on a regular basis, an in-house quality assurance check or report. Neither the deputy Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 Page 17 manager or the activities worker were aware that a survey of residents and visitors views had been sought. The minutes of the last residents meeting held in 07/02/06 showed that residents are encouraged to voice their views and are actively involved in issues relating to the running of the home. The deputy manager commented that residents meetings are held and they are encouraged to voice their opinions. The home deals with residents pocket monies and a receipt book in which the accounts of monies paid to the hairdresser or chiropodist are entered. All funding is paid direct to the company by standing order or checks. Residents monies were checked against the record of monies held on their behalf and it was found that an accurate account is kept. There was no evidence available to show that the supervision of all care staff is undertaken. The deputy manager and senior on duty as well as care workers confirmed that they had not received supervision or appraisals. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks and fire alarm inspections have been undertaken. Care staff also receive fire training as part of the homes initial training and as a regular training event. Certificates were available showing that bath hoists and the shaft lift had been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 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 2 3 Standard OP3 OP3 OP7 Regulation 14(d) 14(a) 15(b) Requirement All prospective residents must be written to confirming that the home can meet their care needs. All residents must have a preadmission assessment carried out by the home. The home must carryout monthly reviews of the care needs of residents and record that this process has been undertaken. The home must make arrangements to ensure that residents are given their medication when required. 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. (Timescale of 15/01/06 not met). Timescale for action 25/06/06 25/06/06 25/06/06 3. OP9 13(2) 25/06/06 4. OP10 12(4)(a) 25/06/06 5. OP15 16(i) The home must ensure that 25/06/06 written information is available in residents files and to the cooks regarding residents dietary needs and that sugar free cakes and puddings are made DS0000061520.V287919.R01.S.doc Version 5.1 Page 20 Fern Dene Care Home 6. OP15 16 available. The home must ensure that likes and dislikes include those drinks that residents prefer. (Timescale of 15/01/06 not met). The home must ensure that all staff have undertaken safeguarding vulnerable adults training. The home must ensure that all staff employed have a current photograph and means of identification in their personnel files The home must provide up to date evidence that all care staff undertake training. (This requirement is Partly met and a new timescale has been given) The registered person must establish and maintain a system for reviewing at appropriate intervals the quality of care provided at the care home and inform residents of the outcomes of any survey undertaken. Members of staff are to be in receipt of regular supervision and annual appraisals. (Timescale of 31/07/05 and 15/01/06 not met) 25/06/06 7 OP18 13(6) 25/07/06 8 OP29 19(1) 25/06/06 9. OP30 18(c) 25/06/06 10 OP33 24 (a)(b 25/07/06 11 OP36 18 25/06/06 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 OP16 Good Practice Recommendations The home should have a complaints process that DS0000061520.V287919.R01.S.doc Version 5.1 Page 21 Fern Dene Care Home 2 OP19 empowers residents and which written in the organisations format giving the outcomes of the complaint. The home should have a rolling maintenance programme which shows which rooms are to be redecorated etc. Fern Dene Care Home DS0000061520.V287919.R01.S.doc Version 5.1 Page 22 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.V287919.R01.S.doc Version 5.1 Page 23 - 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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