Inspection on 08/11/05 for Fern House

This inspection was carried out on 8th November 2005.

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 no outstanding requirements from the previous inspection report, but made 4 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 07/12/06

Fern House 14/03/06

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 Julie Playfer Unannounced Inspection 8th November 2005 10:00 Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fern House DS0000009563.V254343.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 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.V254343.R01.S.doc Version 5.0 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.V254343.R01.S.doc Version 5.0 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 1st March 2005 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, providing accommodation in six single bedrooms, none of the rooms have an ensuite facility. The shared space is provided in 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 staffing level provided is in accordance with guidance previously issued by Local Authority. As such one member of staff is on duty at all times during the waking day and one member of staff sleeps on the premises during the night. Fern House DS0000009563.V254343.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 took place over seven hours on 8th November 2005. The previous inspection took place on 1st March 2005. No additional visits have been made to the home since the last inspection. On the day of inspection there were 6 residents accommodated at the home. Information was obtained from staff records, care records and policies and procedures. The inspector also spoke to the residents, the staff on duty and the registered manager. A partial tour of the premises was also undertaken. What the service does well: What has improved since the last inspection? Since the last inspection a new care plan format had been introduced, which covered the residents’ needs and provided staff with guidance on how to meet these needs. Improvements had been made to the overall management of medication and all records seen were complete and up to date. The bathroom and shower room had been refurbished and retiled and the lounge, hallway, one of the bedrooms and kitchen had been decorated. The lounge and one bedroom had also been fitted with a new carpet. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 6 The registered manager had implemented systems to monitor the quality of service to ensure the home was run in the best interests of the residents. 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.V254343.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Residents were provided with useful and informative information about the services and facilities provided in the home. Resident’s needs were properly assessed prior to admission. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. Both documents were presented in a suitable format and had been distributed to all residents. The registered manager confirmed that the information had also been verbally explained to the residents. One resident had been admitted to the home since the last inspection. It was evident an assessment of needs had been carried out by a social worker prior to the person’s admission. An assessment had also been completed by the registered manager. Advice from specialist services had been sought as necessary. The resident had visited the home on two occasions, before making the decision to move into the home. This provided the opportunity to meet the other residents and staff and view the available room. All residents had been issued with a contract/terms and conditions, however, this document had not been completed with the new resident. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 9 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 and 9 The care planning system fully addressed the needs of the residents and provided clear guidance to staff on how these needs were to be met. Relationships within the home were good. The established consultation arrangements ensured residents were able to participate in all aspects of life in the home. EVIDENCE: Since the last inspection the care plan format had been revised and improved. From the case files seen, it was evident each resident 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 ensure all needs were met. It was apparent the plans had been reviewed at least every six months and agreed with the resident. The plans had been updated in respect to any changing needs. The care plans were detailed and were written in a suitable format for both the staff and residents. It was noted the plans had been signed by the resident to indicate their participation and agreement. It was the practice of the home to support responsible risk taking and policies and procedures supported this approach. Detailed risk assessments and Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 10 management strategies covered activities indoors and in the wider community and were included within the residents’ plans. During conversations with residents, it was evident they were consulted both informally and formally and they were able to participate in life in the home. From the minutes seen of the resident’s meetings, it was evident a wide variety of topics were discussed and contributions had been made by the residents. It was also noted that one resident was invited to attend a part of each staff meeting. This role was offered to each resident in turn. The residents were supported with their financial affairs and detailed written records were maintained of all transactions. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 11 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): 11, 12, 13, 14, 15, 16 and 17 Residents were provided with opportunities to engage in a range of leisure activities and were supported to use community facilities. The residents maintained strong links with their families and enjoyed positive relationships within the home. Arrangements were in place to ensure the residents participated in the life of the home and their rights were respected. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills. Residents were encouraged and supported to participate in the life of the home and carried out domestic tasks commensurate with their abilities and interests. These tasks included tidying bedrooms, helping in the kitchen and light domestic chores, such as dusting. Residents engaged in activities in the local community, which included walking, going to the cinema, shopping and restaurants. Staff provided assistance with activities as necessary and had knowledge of events in the nearby area. Since the last inspection four residents had been on holiday to Margate, the residents Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 12 spoken to said “everyone had a lovely time”. Three residents had also been on a trip to Southport. The residents pursed a number of educational activities, which included attending the local college and day centre. One person also had a part time job in a restaurant. The residents were supported to maintain relationships with their friends and families. All residents were entered onto the electoral register and exercised their vote by attending the local polling station or by entering a postal ballot form. The residents said the routines in the home were flexible and were designed around their arrangements for the day. As such, there were different routines at the weekend. The registered manager maintained a record of meals served to residents, which included variations served to the main menu. The residents said they liked the meals and there was always plenty to eat. The residents described the meals as “very nice” and “very good”. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The residents’ healthcare needs were identified and met. Personal support was provided in a manner, which respected the residents’ rights to privacy and dignity. Appropriate systems were in place to handle medication, however, staff should receive accredited medication training. EVIDENCE: The residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. Residents spoken to confirmed personal support was provided in private and their rights to privacy and dignity were respected. The registered manager and staff ensured consistency and continuity for residents by the use of a key worker system. A record was also maintained of individual likes and dislikes as part of the assessment and care planning processes. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. Since the last inspection improvements had been made to the management of medication. Risk assessments had been devised in relation to the selfFern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 14 administration of medication and all details on the prescription label had been recorded on the medication administration record. In addition, the pharmacist had provided a description of the each tablet and the registered manager had maintained records of advice sought from the pharmacist. However, not all the staff designated to administer medication had received accredited training. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Systems were in place to ensure any concerns of residents 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 listen to and act on the views and concerns of residents. This was achieved during daily conversation, one to one discussion with residents and their key workers and residents’ meetings. The complaints procedure was included in the service users guide along with a simplified pictorial version. The procedure set out the stages and the timescales for the process of dealing with complaints and included the address of the Commission. However, it was noted the complaints procedure issued to the resident new to the home did not include the name of the correct registered manager. The home had a copy of “No Secrets in Lancashire” and a specific procedure for responding to any suspicions or allegations of abuse. There was a whistleblowing policy and procedure in place for the reference of staff. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 16 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, 26, 28 and 30 Fern House provided homely and clean accommodation. Residents were able to personalise their bedrooms and create an individual space suitable for their needs. EVIDENCE: Fern House is a mid terrace property located approximately half a mile from Burnley town centre. The premises are in keeping with the local community. Accommodation is provided in six single rooms, none of the rooms have an ensuite facility. The home also provides one bathroom and one shower room. Since the last inspection the bathroom and shower room had been refurbished and retiled to good effect and the lounge, hallway, one of the bedrooms and kitchen had been decorated. The lounge and one bedroom had also been fitted with a new carpet. However, the wardrobe in room 12 had not been stabilized and the laminate flooring was lifting slightly by the sleeping-in room door. The furnishings and fittings were domestic in character and of a satisfactory quality throughout. At the time of inspection, the premises were comfortable, clean and free from offensive odours. There were systems in place for the maintenance and renewal of fabric and decoration. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 17 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): The home had sufficient staff on duty to meet the needs of the residents. However, the staff recruitment process must be improved to protect the people living in the home. EVIDENCE: Staff were issued with job descriptions, which set out their roles and responsibilities. It was evident the job descriptions were linked to meeting the needs of the residents. From discussions with staff and registered manager during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were regularly reviewed and additional staff were placed on duty, where necessary, to meet the needs of the residents. At the time of inspection a useful recruitment and selection checklist was held on each personnel file. However, there was no specific recruitment and selection procedure seen which incorporated the requirements of the Care Homes Regulations 2001 (as amended) and the POVA scheme. Two files were inspected of members of staff new to the home. Both people had completed an Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 18 application form and attended an interview. However, there were shortfalls noted in the recruitment procedure these included gaps in employment history without a satisfactory explanation of gaps, one reference which was received after the person commenced working in the home, not seeking a reference from a current employer and not seeking a reference from previous employment which involved work with vulnerable adults. All new employees undertook an in house induction and a “Skills for Care” induction training course. Each member of staff had a training and development plan and had attended various training courses, which included anti-discriminatory practice, risk assessment and adult abuse awareness. A training plan was available for the staff team as a whole and the registered manager was able to identify future training needs. None of staff had completed NVQ level 2, but one member of staff was due to commence working towards this qualification in January 2006. Staff meetings were held on a regular basis. The meetings gave the opportunity to staff to share experiences and develop teamwork. The registered manager ensured staff received supervision at least six times a year and had an annual appraisal of their work performance. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 19 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, 40, 41 and 42 The management approach promoted positive relationships between the staff and residents and the overall atmosphere was open and friendly. Effective systems were in place to protect the health and safety of residents. EVIDENCE: The registered manager had the overall responsibility for the management of the home and had a job description, which reflected the aims and objectives of the home. Since the last inspection, the registered manager had enrolled to undertake an NVQ 4 in management and care. The management approach was consultative and there were systems in place to consult both staff and residents. Relationships within the home were positive and staff spoke about the residents with respect. In turn the residents described the staff as supportive and approachable. The home achieved an Investor’s in People Award in October 2000, which had been reaccredited in April 2002. The registered manager had developed Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 20 systems to monitor the quality of care, which were based on regular audits. However, an annual development plan had not been devised. Satisfaction questionnaires distributed in 2004 had been collated and the results had been discussed with the residents. The registered manager was in the process of distributing satisfaction questionnaires for 2005 at the time of the inspection. There was a full set of policies and procedures, which had been signed and dated by the registered manager. With the exception of the staff records all other records seen were kept in accordance with the Care Homes Regulations 2001. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation was seen during the inspection which, confirmed gas and electrical systems were serviced at regular intervals. To minimise the risk of scalding the bath and shower had been fitted with preset valves. The fire log demonstrated staff and residents had participated in regular fire drills. Arrangements were in place to store hazardous substances securely and risk assessments had been carried out for all safe working practice topics. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x 2 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fern House Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 3 x DS0000009563.V254343.R01.S.doc Version 5.0 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 Requirement All residents must be issued with a complaints procedure, which includes to the name of the correct registered manager. The wardrobe in room 12 must be stabilized. All records and documentation relating to the recruitment of new staff must be collated and maintained in line with the requirements of the Regulations. Appropriate refrences must be sought and received before a person commences work in the home or has any access to the residents. An annual development plan must be devised based on a systematic cycle of planning, action and review reflecting aims and outcomes for residents. Timescale for action 15/12/05 2 3 YA26 YA34 13 (4) 19 Sch 2 15/12/05 08/11/05 4 YA39 24 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 23 No. 1 2 Refer to Standard YA5 YA20 Good Practice Recommendations A contract/statement of terms and conditions should be completed with the residents new to the home. The registered provider should ensure that staff training in relation to medication is accredited and includes a basic knowledge of how medicines are used and how to recognise and deal with problems in use, as well as the principles behind all aspects of the home’s policy on medicines handling. The registered providers should monitor the condition of the laminate flooring in the hallway, which was lifting slightly by the sleeping-in room door, to ensure this does not become a tripping hazard. 50 of the care staff should achieve NVQ level 2 by 2005. A thorough recruitment and selection procedure should be devised, which incorporates the requirements of the Care Homes Regulations 2001 9 (as amended) and the POVA scheme. The registered manager should complete an NVQ 4 in Management and Care. 3 YA28 4 5 YA32 YA34 6 YA37 Fern House DS0000009563.V254343.R01.S.doc Version 5.0 Page 24 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. 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