Inspection on 07/12/06 for Fern House

This inspection was carried out on 7th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fern House 09/12/08

Fern House 14/03/06

Fern House 08/11/05

Fern House 01/03/05

Fern House 07/09/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Fern House 28 Accrington Road Burnley Lancashire BB11 4AW Lead Inspector Mrs Pat White Unannounced Inspection 7th December 2006 10:00 Fern House DS0000009563.V310890.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 House DS0000009563.V310890.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 House DS0000009563.V310890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fern House Address 28 Accrington Road Burnley Lancashire BB11 4AW 01282 451950 01282 690649 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) Mr Shaun Martin Brelsford Mrs Amanda Jane Brelsford Mrs Joann Whittaker Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must at all times, employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection Date of last inspection Brief Description of the Service: Fern House is registered with the Commission for Social Care Inspection to provide personal care and accommodation for six adults 18 - 65 years with a learning disability. The home is a mid terrace property. There are six single bedrooms, none of the rooms have an en suite facility, and the shared space consists of two lounges and a dining kitchen. The home is located approximately half a mile from Burnley town centre. There is a yard area at the rear of the property and a garden at the front. The service users are encouraged to take part in a variety of activities according to their abilities and interests, and these include going to college and day centres. There was routinely one member of staff on duty at all times during the waking day and one member of staff sleeps on the premises during the night. Two members of staff were on duty at certain times if the needs of the service users required it. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Fern House on the 7th December 2006. The purpose of this inspection was to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Adults (aged 18 – 65), and checking the progress made on the matters that needed improving from the previous inspection. The inspection included: talking to the service users, touring the house, observation of life in the home, looking at service users’ care records and other documents, written information supplied by the home (the pre inspection questionnaire) and discussions with the manager and a member of staff on duty. With staff help, the six service users completed and returned, survey questionnaires from the Commission. All the service users were spoken with and observed throughout the visit to the home. Their views are included in the report. What the service does well: Service users were given useful information about the home, some of which was in a form that they could understand with pictures being used. Before the service users went to live in the home written information about them, and what care and support they needed, was obtained. This helped to make sure that Fern House was the right place for people to live in, and that staff understood them and what they had to do to look after them. The service users’ care and support was well planned and made sure that they were well looked after, and had interesting and enjoyable things to do. During the week some service users went to college and others went to a day centre. They also were encouraged to take part in hobbies and leisure activities such as bowling and shopping. Some service users were able to keep in touch with their families and were encouraged by the staff to do so. Service users could choose some of the things they wanted to do, and things that happened in the home. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 6 There was good written information about the service users, and what support they needed and what they liked to do each day. This included a “person centred plan” that service users wrote with the help of staff. The service users and staff appeared to get on well and the service users said that staff were “nice” and “looked after them well”. One said she “got on well” with her key worker. There was a friendly and warm atmosphere in the home. The service users’ health was well looked after and there were different ways of making sure that they had all the health care they needed such as “health action plans”. Service users said that they enjoyed the meals and could choose some of the things they had to eat. Systems and policies and procedures were in place to ensure service users were listened to and protected from harm. The service users knew who to speak to if they were unhappy about anything in the home and there were some pictures on the notice board to help them know what to do. The home was comfortable, homely, safe and clean and fresh. Staff were undertaking the right training so that they knew how to look after the service users who lived at Fern House. What has improved since the last inspection? Some of the recommendations made at the last inspection have been met. The manager had completed the right qualification for her job as manager of the home and more members of staff had gained the right qualifications. Some parts of the house had been improved – some carpets had been replaced and some bedrooms had been decorated. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 7 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. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 8 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 House DS0000009563.V310890.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Service users were provided with useful and informative information about the services and facilities provided in the home. Service user’s needs were properly assessed and reviewed. The service users felt they had a choice of whether or not they wanted to live at Fern House. EVIDENCE: In the questionnaires completed the service users said that they had some choice about moving into the home. One said the “social worker had asked” if they wanted to, and another said, “dad had asked”. All said they had enough information to enable them to make a choice. The service users had written information about the home - the Service User Guide - in their bedrooms. However this needed reviewing and updating, for example the reference to “Boundary Place Dispersed Housing Schemes” should be removed. There had been no service users admitted to the home since the last inspection visit. However, it was evident from the records viewed that a full assessment of needs had been carried out by social workers, and the manager of the home, prior to the service users’ admission. It was also apparent that the last service user to be admitted had visited the home the home before moving in to see if she liked it. However these “introductory visits “ were not recorded and the assessment documentation limited making it likely that some important information would not be recorded. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 10 Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 11 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, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The care plans had detailed and useful information about the needs of the service users and provided guidance to staff on how these needs were to be met. Relationships within the home were good and assisted the service users to make choices about their lives and participate in the life in the home. However there was no supporting written evidence to support the decisions made about service users not being able to manage some aspects of their lives. EVIDENCE: From the service users’ records seen, it was evident that each service user had a plan of care, based on the assessment of needs. The plans set out in detail the action needed to be taken by staff to care for and support people. It was also evident that the needs and the care required were being reviewed. The care plans also included “person centred plans” which included service users’ preferences, preferred routines and activities. The written information therefore enabled staff to understand the different and individual, sometimes complex, circumstances and needs. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 12 Discussion with the service users and staff confirmed that the service users had choices in their everyday lives, about what to do each day, and about their preferred routines. Relationships between the staff and service users were such that service users were listened to and their views taken into account. The questionnaires completed by service users confirmed this. All stated that that they “always” make decisions about what they do each day. All said they could do what they wanted “during the day, in the evening, and at the weekend”. However there was routinely only one member of staff on duty so the choice of the service users’ activities could be restricted, particularly at weekends (see standard 33). Service user’s meetings were held and service users were encouraged to express their views on all aspects of life in the home. Service users were encouraged to be independent and take some responsible risks that were supported by written risk assessments. However none of the service users managed their own finances or their medication. Though service users had signed written authorisations giving staff permission to manage this aspect of their lives, there were no written explanations or risk assessments to support these decisions. It was therefore not clear why some service users could not be more independent in these matters. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 13 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Service users had good opportunities to take part in a range of appropriate activities and were supported to use leisure and community facilities. The service users maintained links with their families and enjoyed positive relationships within the home. Service users were encouraged to participate in the life of the home. The meals served were healthy and varied and appeared to suit the service users’ preferences. EVIDENCE: Service users attended college courses and day centres in line with their interests and capabilities and which included learning in “life skills”. This gave them the opportunity to meet people outside the home environment and encouraged greater independence. One service user helped at a luncheon club and had a part time job in a restaurant and another service user helped in a charity shop. On the days when service users were at home they were given the opportunity of taking part in such activities as baking, art work and shopping. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 14 The service users used leisure facilities in the local area, which included pubs, the cinema, the leisure centre and restaurants. Some service users regularly attended a church group specifically for people with learning disability. This showed that service users were encouraged to develop spiritually. The pre inspection questionnaire listed the following activities: shopping, luncheon club, cinema, park, leisure centre, swimming, day trips, church, cooking, drawing, music nights, and writing. Service users spoken with were enthusiastic about college activities, leisure activities, visiting a local restaurant, a recent holiday in Llandudno and the forthcoming Christmas festivities. The holiday was included in the contract price. Families and friends were able to visit the home at any time. Some service users enjoyed regular contact with their relatives and the registered manager and staff supported these relationships. The service users said the routines in the house were flexible and were arranged around their daily activities. Some preferences were recorded on the care plans. Service users were able to participate in the chores of the house, such as cleaning and tidying their bedrooms, preparing food and washing up. Some service users were able to prepare their own snack meals. However none of the service users managed their own medication or finances and these decisions were not underpinned by written evidence, such as risk assessments. Therefore for some service users who were relatively independent, it was not clear why they could not manage these aspects of their lives (see standard 9). The food served in the home was healthy and enjoyed by the service users. Menus supplied showed a healthy choice for the 3 main meals of the day, including a choice of two cooked options for the main evening meal. Service users went shopping with the staff and helped choose the food. They were able to participate in the preparing, cooking and serving of food and were encouraged to do so. At the visit to the home staff were observed asking service users about their choice of food and snacks. The evening meal was observed and appeared healthy and appetising. Service users said they enjoyed this meal, and the food in general and spoke enthusiastically about their favourite meals. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Personal support was provided in a manner, which respected the service users’ rights to privacy, dignity and independence. The service users’ physical and emotional health was monitored and their health needs were met. Service users’ medication was in general administered safely, but some practices could be further improved to further safe guard service users’ health. EVIDENCE: With respect to personal support, service users were given prompts and supervision according to their individual needs, and in a way that promoted dignity and independence. The service users’ individual care plans set out the personal support each service user required and provided details of how this support was to be delivered. The registered manager and staff ensured consistency and continuity for service users by the key worker system of support. A record was also maintained of individual likes and dislikes as part of the assessment and care planning processes. Preferred routines such as times of getting up and going to bed were also recorded and respected. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 16 The importance of service users’ rights to independence, privacy and dignity was included in the Induction training for new staff and it was clear through talking to service users and staff that these rights were respected. The records, and discussion with the staff, showed that the service users’ physical and emotional health was monitored, and health problems addressed. All service users had a “Health Action Plan” which involved an annual health check and a medication review. Records, including the care plans and the pre inspection questionnaire, also showed that the service users had appropriate services from the psychologist, speech therapist, chiropodist, optician and dentist. Medication procedures and practices in general were safe and there were some good practices, such as the manager checked the prescriptions prior to dispensing, there were written explanations of when “when required medication” (PRN) should be given and all staff who administered medication had appropriate training. However some procedures and practices could be improved. Though the policies and procedures covered most aspects of the recording, storage, handling, administration and disposal of medication, they did not cover the receipt (and recording) of medication into the home, drug errors and covert administration. Also the policy for “homely remedies” was incomplete. All service users had given consent for staff to administer their medication but there was no supporting evidence to indicate that service users were not capable of managing their medication. Also one service user was responsible for taking a prescription mouthwash but there no risk assessment to support this. The records kept of the medication administered (“MARs”) were in general accurate, but not all the medication received into the home was correctly recorded and there were no records kept of the prescriptions ordered. Also there were no clear instructions for the “variable dose” medication for one service user whose records were viewed. Medication was stored securely, including that requiring storage below room temperature, but there were no records of temperature monitoring. There was evidence that service users received the correct medication at the right time. However for one service user who attended a day centre medication was not given at the time it was taken from its original container and there was no written evidence that the day centre had received the medication or given it correctly. At the time of writing the report, and following advice from the Commission’s pharmacy inspector, a safer system had been developed. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 17 Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 18 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Systems were in place to ensure that any concerns of service users would be acted upon. Appropriate policies and procedures were available to respond to any allegations or suspicions of abuse. EVIDENCE: Both informal and formal arrangements were in place for the registered manager and staff to listen and act on the views and concerns of service users. These included the daily conversations, one to one discussions with service users and their key workers, and service users’ meetings. There was a complaints procedure which included pictures to help service users understand to whom they could speak. No complaints had been made since the last inspection. Service users spoken with stated that they had no complaints. They were all happy in the home, and one said, “I don’t want to live anywhere else”. Also all service users who completed the survey questionnaires, and the ones spoken with at the site visit, stated that they knew who to speak to if they were not happy and that they knew how to make a complaint. There were appropriate policies and procedures for the protection of vulnerable adults, and responding to any suspicions or allegations of abuse. All staff had undertaken training on abuse (including people with learning disability) and including dealing with challenging behaviour. There had been no recent suspicions and allegations of abuse. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 19 Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 20 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, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The home was comfortable, homely, well maintained and in keeping with the service users’ age group. The service users were able to personalise their bedrooms and create an individual space suitable for their needs. All areas of the home were clean and fresh. EVIDENCE: A tour of the premises showed that the premises were homely and comfortable, and that the 6 single bedrooms had been decorated according to the personal preferences of the service users. Three bedrooms had been decorated and a new bathroom installed since the previous inspection. The PIQ stated that the landing and stairs carpets had been renewed. There was a plan for maintenance to help ensure that jobs were undertaken promptly and a leak in the roof was in the process of being repaired at the time of the site visit. The service users had personalised their rooms with posters and other possessions, for example TVs and music players. Two service users had their own computer. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 21 The premises were safe; the fire regulations were met and the hot water tested at random outlets was found to be within an acceptable range to ensure service users were safe from scalding. The home was clean and hygienic in all areas seen at the time of the site visit, and all service users stated in the survey questionnaires that the home was “always fresh and clean”. To help ensure good standards of hygiene, staff had undertaken an Infection control course. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 22 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, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The service users benefited from a competent and qualified staff team. However it was not guaranteed that the needs, particularly with respect to leisure activities, of all the service users could be met when there was only one member of staff on duty. Service users and staff benefited from good staff support and supervision. EVIDENCE: From discussions with a member of staff and the registered manager during the site visit, it was evident that staff had a good understanding of the service users’ needs and knew the service users well. At the site visit staff were observed interacting with service users in a respectful, positive and pleasant way. At the time of the inspection 3 out of 5 members of staff had completed NVQ level 2 training or above, that is, 60 of the care staff. The staff rotas and discussion with staff confirmed that there was only one member of staff on duty most of the time, and this included at the weekends. Two members of staff were on duty if a service user had to be accompanied somewhere, and also if any service user required consistent one to one attention. However at the weekends when service users were not at college or the daycentre, the options for their choice of activities could be restricted with only one member of staff on duty. Also two service users were described as Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 23 having “challenging behaviour”, but there was no written evidence to demonstrate the risks faced by a lone member of staff and how these risks were eliminated or minimised. In the internal service quality audit undertaken by the registered provider two members of staff stated that at times there should be more staff on duty. There had been no member of staff recruited since the previous inspection so this standard was not fully assessed. However the requirement made at this last inspection, regarding the references of the last person recruited, was met. All staff had training and development files with records of training undertaken. This showed that staff had completed an in house induction in accordance with Government guidelines. These records and information supplied on the pre inspection questionnaire showed that staff undertook training in, first aid, moving and handling, food hygiene, medication management and adult abuse. Some had also undertaken training in challenging behaviour. The member of staff spoken with confirmed these training opportunities. Records and discussion with staff confirmed that the manager carried out one to one supervision with care staff and annual appraisals. Staff felt they benefited from this support. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 24 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, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. Residents benefited from stable and committed management that ensured positive relationships between the staff and the residents. The quality assurance systems ensured the residents’ views underpinned the development of the home. The health and safety of both residents and staff was promoted but some improvements could be made, for example in fire safety. EVIDENCE: Since the previous inspection the manager had recently completed her NVQ level 4 in management and she was awaiting the results. She confirmed that she had undertaken courses in challenging behaviour, medication, first aid and infection control. The manager had been in post for a number of years and was clearly committed to the welfare and best interests of the service users. Through discussion with service users and observation at the time of the site visit, it was clear that the manager created a caring, open and happy Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 25 atmosphere. The member of staff spoken with said the manager was supportive, approachable and committed to her job. Regular staff meetings were also held that assisted communication and allowed staff to participate in making decisions. The home carried out its own quality monitoring measures and annual service user questionnaires were last completed in September 2006. These were in a suitable format with pictures to assist those who could not read. Individual service user comments were dealt with. Questionnaires were also sent to relatives and the social work team. Service users’ meetings were held about 6 times yearly, and this assisted service users to participate in the running of the home. The home’s health and safety policies and procedure helped to ensure a safe environment in which to live and work. However some improvements should be made. Staff records demonstrated that the staff had received appropriate health and safety training including moving and handling, external fire safety training and first aid. However some members of staff needed refresher courses in first aid. The fire equipment, gas installations, electrical wiring and electrical appliances had been maintained and serviced appropriately. Suitable records were kept of fire drills and fire alarm tests. There had been a fire safety inspection in Feb 2006. However there was no record of this available at the site visit, and an up to date fire risk assessment had not yet been completed. Also there was no evidence that the home’s water supply did not pose a risk of the spread of Legionella. As stated previously in the report there was no risk assessment to support staff working alone in the home and to help ensure their protection. Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 26 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 2 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 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x 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 3 3 2 x 3 3 3 X X 2 x Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 27 Yes 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 YA1 Regulation 6 Requirement Timescale for action 31/01/07 2 YA20 3 YA20 4 YA33 5 YA42 The Service User Guide must be reviewed and updated to ensure that the information is accurate. 13(2) Medication policies and procedures must be developed to include all aspects of medication management in the home, including the receipt of medication into the home, drug errors, covert administration and the use of homely remedies. 13(2) Accurate records must be kept of all medication received into the home, including ensuring these records are dated and signed by two members of staff. Records must also be kept of the prescriptions ordered. 18(1)(a) The registered person must review the staffing levels in the home, and ensure that there are always suitably qualified and competent staff, in sufficient numbers to meet the needs of all the service users. 23(4)(a)&(c) The registered person must ensure that the DS0000009563.V310890.R01.S.doc 31/01/07 12/01/07 31/01/07 28/02/07 Fern House Version 5.2 Page 28 recommendations made in the fire safety inspection in 2006 are complied with and that the home’s fire risk assessment is completed. 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 YA2 Good Practice Recommendations The in house assessment documentation should be developed so that there is more space to write the detailed information required, and the “Introductory visits” should be recorded. Decisions about whether or not service users can manage their own finances and medication should be supported by written explanations and risk assessments so that it is clear why the service users cannot be independent in these matters. Service users who are capable of administering their own medication should be supported to do so and this should be supported by a risk assessment to ensure safe procedures are followed. The criteria for which dose should be given for “variable dose” medication should be clarified and written down on or near the MAR sheets The temperature of the medication storage area should be regularly monitored and recorded to ensure medication is stored safely. It is recommended that a risk assessment is carried out to determine the risks associated with members of staff working alone in the home and how the risks should be minimised or eliminated. The registered person should ensure that the home’s water supply does not pose a threat of the spread of Legionella. The registered person should ensure that staff have up to date first aid training. 2 YA9 3 YA20 4 5 6 YA20 YA20 YA33 7 8 YA42 YA42 Fern House DS0000009563.V310890.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 House DS0000009563.V310890.R01.S.doc Version 5.2 Page 30 - 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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