Inspection on 17/05/05 for Fern Lea

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fern Lea 30/05/07

Fern Lea 22/11/05

Fern Lea 14/02/05

Fern Lea 21/09/04

Fern Lea 12/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Fern Lea 53 Pearson Park Kingston upon Hull HU5 2TG Lead Inspector George Skinn Unannounced 17 May 2005 09:30 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 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 Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fern Lea Address 52 Pearson Park Kingston upon Hull HU5 2TG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01482 441167 01482 474719 Richard & Carol Sheehan Stephen & Jane Brown Mrs Carol Sheehan Care Home 20 Category(ies) of OP Old Age (20) registration, with number DE(E) Dementia - over 65 (20) of places Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14/02/ 2005 Brief Description of the Service: Fern Lea is a large Victorian house in Pearson Park approximately 1½ mile from Hull City centre. It offers permanent and respite accommodation for up to 20 older people of either gender, who may also suffer from dementia. The home usually operates with 19 residents when full but has spaces for 20. Staff provide a range of personal care and have the added knowledge of the Registered Manager (also one of the Registered Providers), who is a qualified nurse. Nearby are local shops, public houses and churches. The home is near to major bus routes into Hull. Accommodation is on three floors (two of these are split level with additional stairs), there is a chair lift from the ground to first floor only. There are currently seven single and six double bedrooms in use, but these are interchangeable, with many rooms reaching the requirement of 16m². Communal space consists of a lounge and dining room. There is a small, enclosed patio/garden area to the side of the home. The front garden is mainly for car parking with some seating areas. The grounds are well maintained and the décor in the home is of a good standard. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken over 7 hours. The building was looked at and some records were inspected. Six of the nineteen residents and three of the staff group were spoken with. This included the manager/registered provider. This is the first visit to the home since the last inspection in February. What the service does well: What has improved since the last inspection? What they could do better: It is very difficult to identify anything that the home could do better as it is run very much with the best interest of the residents as the main philosophy and this is more than achieved. The manager acknowledges that they are not perfect but is always re-assessing and auditing the service offered to see if there are areas for improvement. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 6 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 Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 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 standard(s) 3 All residents including those who are self funding, are assessed prior to their stay at the home. This ensures the residents needs can be met by the staff. EVIDENCE: There has been no change to the systems for obtaining information from local authorities and undertaking an assessment of residents needs since the last inspection. For individuals referred through a local authority care management team the manager obtains a copy of the assessment and care plan this is also applicable to those who are self funding. From a sample of records examined it was evident that the Manager and staff in the home complete a thorough needs assessment, based on nine areas of daily living. This is used to write a plan of care for daily living for each resident. These are comprehensive and clearly presented. Those residents interviewed stated they had made a positive choice to live at the home. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 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 standard(s) 7 All residents have a comprehensive care plan which ensures that their health and personal care needs are well maintained and met. EVIDENCE: There has been no change to the systems for compiling plans of care since the last inspection. All the residents have a very detailed and comprehensive plan of care, completed from detailed information determined at assessment. The action to be taken by staff for each area of care is listed against each assessed need. There are risk assessments completed for areas of care where risk of injury or deterioration could occur, such as for moving and handling and pressure relief. Staff and especially key workers review plans of care each month, and a formal review with stakeholders present, is held every six months. These are recorded in meeting minutes and copies provided to all parties and held on file. Residents and their families, where appropriate, are involved in the compilation of plans of care. Some of the residents interviewed were aware that files were kept detailing personal information and were aware that reviews are held on a regular basis. The staff were more than aware of the care needs of the residents and could provide detailed information. They were also aware of the issues surrounding confidentiality. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 10 Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 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 standard(s) 12 & 15 Residents’ lifestyle experiences within the home matches their expectations and preferences; and satisfies their social, cultural, religious and recreational interests and needs. Residents receive a wholesome appealing balanced diet in pleasing surrounds at times convenient to them. EVIDENCE: There has been no change to the flexible approach to daily routines since the last inspection. Residents set their own routines according to their wishes and preferences, but there are some routines within the home, which enable consistency and manageability Staff were observed to be flexible in their approach and meet needs as they arise, as well as planned. Staff encourage individuality and exercising of choice. Details of individual needs are recorded in plans of care. Forthcoming events and activities are posted on the notice board in the hallway. Menus are rotated according to season and choice, food purchased is fresh, baking and cooking is done by using fresh and basic ingredients and nothing is Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 12 bought in already prepared. The cook prepares liquidised diets in a very presentable way, semi-solid and in individual portions to maintain colour and flavour. The mid-day meal was eaten with the residents and it was very well prepared and presented. During the afternoon the cook prepared a stew for tea which smelt very appetising. The residents were very positive about the quality of the food one resident said “the food here is always nice” another said “we always get a good choice at tea time including a hot meal if we want”. All those residents interviewed commented on being able to come and go as they pleased one resident said “we are never forced to do any thing we don’t want to”. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 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 standard(s) 18 Residents know how to complain and are confident in doing so. The homes procedures ensure they are protected from abuse. EVIDENCE: The home has a copy of the local multi-agency guidelines for the protection of vulnerable adults and a policy on whistle blowing. Staff were able to discuss what action they would take if witness to abuse or if coping with aggressive residents. Some staff have attended a “Risk Assessment Based on POVA” course and all commented that this was very beneficial. There is a ‘Prevention of Abuse’ policy compiled by the providers. Staff are trained in handling residents with dementia to ensure their protection and the protection of others. There is a policy on handling finances, and residents money held in safe keeping if they wish, which is recorded appropriately. There are also policies on emergencies and crises, which could arise in the home to protect everyone. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 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 standard(s) 26 The home is maintained to high standard and all areas both communal and private were clean and welcoming, it is clean, pleasant and hygienic. EVIDENCE: The communal areas are bright and cheerful and contain furniture which is comfortable and suited to the needs of the residents. The residents’ private space is clean and comfortable; many of the bedrooms are shared those residents who share rooms have made a positive choice to do so and are given the opportunity not to share if they wish when the shared room becomes single. Residents were happy with their rooms one said she very happy that she could bring personal items as this made it feel “more like home” The bedrooms contained plenty of personal possessions which the residents are encouraged to bring with them. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 15 Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 There are sufficient staff employed to meet the needs of the residents. They are trained and competent to do their jobs. EVIDENCE: Staff files inspected indicated that the home have a robust recruitment and selection process and all staff have undergone a CRB check this includes long term staff. All new staff are CRB checked prior to employment. Rotas indicate that there are enough staff on duty and this was confirmed by visiting relatives and residents. Staff training files indicated that induction and foundation training is provided to newly recruited staff, to the requirements of the National Training Organisation workforce training targets. This was confirmed by the staff when interviewed. There is a training plan in operation, which shows the identified training needs for staff and addresses these throughout the year. Staff have individual training plans identified in supervision and appraisals. Courses covered include health and safety, fire instruction, lifting and handling, first aid, infection control, values and attitudes and the person centred approach, dementia, medication administration, bereavement and a crematorium tour, and basic food hygiene certificate. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 Residents live in a home which is run in their best interest. The residents’ finical interests are safe guarded by the home policies and procedures. EVIDENCE: The home has achieved both parts of the local authority’s Quality Development Scheme. There is a comprehensive quality plan for the year. This includes a series of audits and survey of residents, relatives and staff. There are regular staff meetings. Quality assurance results are discussed at these meetings and minutes are displayed in the home, along with reviews of the quality assurance system. The Manager regularly reviews policies and procedures. Residents confirmed that they are consulted about changes made and they can take as much interests in this as they wish. The home consult regularly with the residents, this is done on an informal basis and all comments are recorded; there is no formal residents meeting but Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 18 they are encouraged to have their say and to express an opinion and this is respected. Resident did say they felt included in the running of the home. The residents financial interested are safe guarded by the homes procedures and staff are well instructed and guided by these. Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 3 x 3 x x x Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 20 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 Regulation none Requirement Timescale for action 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 none Good Practice Recommendations Fern Lea J54_s848_Fern Lea_v227648_170505_Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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