Inspection on 30/05/07 for Fern Lea

This inspection was carried out on 30th May 2007.

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 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 22/11/05

Fern Lea 17/05/05

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 52 Pearson Park Hull East Yorkshire HU5 2TG Lead Inspector Sarah Sadler Key Unannounced Inspection 30th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fern Lea DS0000000848.V334960.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 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 DS0000000848.V334960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fern Lea Address 52 Pearson Park Hull East Yorkshire HU5 2TG 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) 01482 441167 01482 474719 Richard and Carol Sheehan and Stephen and Jane Brown Mrs Carol Sheehan Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named service user who is under the age of 65 (variation application 24923). 22nd November 2005 Date of last inspection 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. Staff provide a range of personal care and have the added knowledge of the Registered Manager, who is 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 to accommodate two people. Communal space consists of a lounge and dining room. There is a small, enclosed patio/garden area to the side of the home, with a new water feature. 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. The accommodation fees range from £ 310 to £332.50, per week. These figures were provided by the registered manager at the time of the visit. Additional charges are made for the hairdresser, chiropodist, newspapers and toiletries. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire completed by the home, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit to the home on the 16th May 2007. This unannounced site visit was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 4.00 pm. The key unannounced visit was undertaken on the 30th May 2007. It commenced at 10.00 and was completed at 16.00 . Time was spent in the main area of the home observing everyday life and short conversations were held with two service users. Further conversations were held with two staff members, one visiting relative, and one GP. A tour of the premises was undertaken and service users’ files and other records were examined. Questionnaires were sent to service users, their relatives/representatives, and health and social care professionals. A good response to this was received and seven service users’ surveys, nine staff surveys, ten relatives surveys, one health professional and three social care professionals surveys were all returned. Overall these surveys were very positive about the home and the care provided. Comments from service users included; ‘I like the home’, ‘ They help you when you have something wrong with you’ and ‘I am very lucky’. All felt that they receive the care and support that they need. Comments from relatives included; ‘We are absolutely delighted with the standard of care he receives, ‘overall they do a good job’ and ‘ The staff are always pleasant and cheerful, it is a real home from home’. All of the responses confirmed that they felt that the home met the individual’s needs either ‘always’ or ‘usually’. Comments from care management included; ‘ Staff care for my client very well’, ‘Provides good care, communication, written information, and encourages family members’ and ‘ Provides residential care to a high standard’. Comments from staff included; ‘ I think all staff do a great job’, and ‘ They give very good care to all residents’. There have been two complaints made direct to the home since the last inspection, which the registered manager stated had been dealt with satisfactorily and evidence of this was seen in records available at the inspection visit. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The recording of the activities undertaken or declined by service users should be improved upon. This would provide information to the home to assist them in assessing how well the leisure needs of the service users are met. All of the service users must be able to access all areas of the home and must not be prevented to do so by the lack of equipment or the design of the home. The registered person should ensure that the laundry floor is impermeable to control the risk of the spread of infection. The quality assurance system should be further developed to ensure that all stakeholders are supported to comment on how the home is meeting the stated aims and objectives. This would allow people in particular the resident service users, to be involved in the home’s development. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to entering the home to ensure that the staff are aware of and can meet their individual needs. EVIDENCE: All of the service user files include an individual comprehensive assessment of the service user and their needs. This is in addition to any assessment completed by the Local Authority when they are placing a service user. All three care management survey responses confirmed that the assessments ensure that information is gathered and the right service is planned. This ensures that the staff are fully aware of the service users’ needs and are sure that they can meet these needs, prior to the service user entering the home. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 10 In addition to the assessments, service user files included a copy of a letter written by the registered manager, to the individual service users to confirm that the home can meet their needs. This re-assures service users, that the home can meet their needs. The registered manager confirmed that the home does not provide intermediate care. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported by a plan of care that assists the staff to continue to meet their health and medication needs, whilst maintaining peoples privacy and dignity. EVIDENCE: All service user care files included a comprehensive plan of care. This identifies the needs of the service user and the actions to be taken in order for those needs to be met. The files were found to be up to date, with monthly and annual reviews of the files and the care provided. The care plan had been signed by the service user to confirm that they agreed with the content. These records ensure that the staff team are fully aware of the up to date needs of the service user and how these are to be met. Service users have their health needs well met. Individual’s care files included detailed information regarding their health needs, how these are met and any Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 12 appointments or visits from health professionals. All of the service users and care management responses were positive in that people receive the medical support that they need. The one GP survey returned confirmed that they felt that the home usually acts appropriately in the management of peoples needs. Also that peoples health needs are usually met. The GP interviewed confirmed that this is a ‘good home’ and that they home worked well to meet people’s health needs. People’s medication needs are met by the home. Medication is stored appropriately and records are kept of the receipt, administration and disposal of medication. All three of the care management survey responses confirmed that people’s medication is managed properly in the home. The one GP survey confirmed that people’s medication is usually managed well. The GP interviewed also felt that the home managed medication well. One service user commented that on occasions their tablets are brought to them with a drink. Unfortunately at times the drink has spilt into the medication container and mixed with the tablets. This has been raised with the registered manager and she has addressed this, although it still occasionally occurs and she is to re-address this. Good practices regarding medication ensure that people’s health and welfare is supported.. People’s privacy and dignity is maintained. All three of the care management surveys and the GP response confirmed that people’s privacy and dignity is met. Service users spoken with felt that their privacy was valued. They commented that ‘ They don’t probe into family matters, and tell me to call them if I want a private chat.’ Staff gave good examples of how to maintain people’s privacy, for example, to cover people up when completing personal care. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to exercise choice, maintain personal relationships and have their leisure needs met. EVIDENCE: All three of the care management survey responses confirmed that the home responds to the different needs of individuals, including if this need was relating to their race or ethnicity. This reflects a service that can meet a range of needs including peoples race and cultural needs. Two of the relatives commented that they felt there could be more activities within the home. During the morning no activities were observed and the registered manager stated that this is because mornings are very busy. Staff sat with the service users in the afternoon and played bingo with them. In discussion staff detailed that different activities take place in the home which include; bingo, music, dominoes and reading books. Service user notes did not include details of the activities undertaken in the home and discussion with the Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 14 registered manager reflected that this is an area the home could improve upon. Six of the service user surveys returned reflected that they felt there are activities within the home, which they could take part in. A range of activities supports people to meet their leisure needs, however without adequate recording of these it will be difficult for the home to adequately assess how well these needs are met. Examples of how service users are supported to make choices were included in the staff surveys and through the staff interviews. These included; What clothes to wear, a choice of food and personal care, when to bathe when to get up or go to bed, and by asking.’ Nine of the relatives responded positively to confirm that they feel the home supports people to live their lives as they choose. Two of the three care management responses confirmed that service users are supported to live the life they would choose. One commented that they felt the home could do more to promote peoples independence. However another felt that promoting independence was something that the home did well. The GP survey confirmed that people are usually supported to live the life they choose. All of the relatives who responded to this question confirmed that the home help their relative to keep in touch with them. All relatives felt that the home keeps them up to date with information. One relative visited during the inspection and confirmed that they are able to visit as they wish. Service user notes reflected that people are supported to telephone, be visited by and go out with friends and relatives. These practices help people to maintain important relationships and friendships in their lives. Service user surveys reflected in all but two of the responses that service users always liked the food provided, the other two service users commented that they usually like the food provided. All of the staff responded in their surveys that they felt the food in the home was ‘excellent’. Comments included; ‘Varied and well presented’ and ‘ A set lunch unless a special diet i.e. diabetic or vegetarian or alternative if they dislike what is on the menu’. There are planned menus to assist in ensuring that the service users receive a balanced diet, with the lunch being the man meal of the day and a lighter meal being served at teatime. People are provided with choices should they not like the main meal. Lunch was observed to be a quiet and relaxed experience with the service users receiving the appropriate support from the staff team in the eating of their meals. This assists to ensure that peoples health and leisure needs are met. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are on the whole, well supported to raise concerns and have these addressed appropriately, whilst also being protected from harm. EVIDENCE: All but one of the responses received confirmed that service users and staff are aware of how to make a complaint. All three of the care management survey responses confirmed that the home always responded appropriately to any concerns that may be raised. Six of the ten relatives responses confirmed that they knew how to make a complaint. However four did not know how to do this and the home may wish to address this issue. There is a complaints procedure on display within the entrance hall of the home. The registered manager confirmed in the pre-inspection material that there have been two complaints to the home since the last inspection, the records kept in the home, reflect that these have been dealt with. Good complaint procedures and practices allow people to raise any concerns so that they may live their lives as they choose. There is a copy of the Local Authority policy the ‘Protection of Vulnerable Adults’ (POVA) held within the home. Responses in the staff surveys and from Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 16 interviews with the two staff members confirmed that all of the staff have a good understanding of the safeguarding of vulnerable people. There have not been any safeguarding adult referrals from the home over the last year. Staff being trained and having support systems in place regarding the protection of vulnerable people helps to ensure that people will be supported appropriately should a concern be raised. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a clean and comfortable home. Which on the whole meets their needs well. EVIDENCE: All areas of the home were very clean and comfortable. All of the service users responded in their surveys that the home is always fresh and clean. The home has been maintained and redecorated as necessary, whilst attempting to retain original features of the building. Most service users have Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 18 single bedrooms. All of these included personal items, for example, family photographs, which reflect the individuality of the service user. One service user has a ground floor room that is located to the rear of the property. Due to some internal steps the service user cannot use the main hallway of the home; and has to access the lounge and dining areas via an outside door. The service users’ relative commented that they are at the moment satisfied with this as the staff assist their relative with this. However during winter the resident has at times to remain in their room as the weather can be too severe and the ground is slippery, making it dangerous for the person to use the external access. The home should address the need for access to the communal areas of the home without having to use an external door. This would ensure that the service user is supported to access all areas of their home, is not restricted in their daily choices and that their needs can be fully met. There is a laundry area in the home. The walls of this are washable, however the flooring is in need of attention. As at present the flooring is not impermeable to help control the risk of infection. Fire checks are completed weekly and maintenance checks are undertaken on fire fighting and alarm equipment. There is also fire risk assessment to identify any areas of risk. The entrance to one service user’s room is identified as a ‘fire’ door and oxygen is in use in this room. However on the day of the visit this door was being held open by a door wedge and so would not self close in the event of a fire. The senior person in charge was later advised as to the risk of this and that this practice should cease until further advice had been gained from the local fire officer, to reduce the risk of harm if a fire occurred. The registered manager confirmed that this was included within the fire risk assessment and that she confirmed with a fire officer that this practice was acceptable. Ensuring good practices in relation to fire prevention helps to ensure that should a fire occur service users are protected from harm. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported by adequate numbers of well recruited and trained staff members. EVIDENCE: Five of the seven staff who responded felt that there were enough staff on duty. The registered manager confirmed that staffing levels have not altered over the last year. Duty rotas provided and discussion with the registered manager confirmed that there are 4 staff on duty throughout the day, which would always include either a senior or the registered manager. Overnight there are always two staff, one of whom is a senior staff member. Good recruitment processes have been developed in the home to ensure that only people who are suitable to work in the home do so. Initially the registered manager and owners of the home knew many of the staff recruited personally. Many of these staff have remained working in the home, reflecting a consistent staff team. New staff all have to attend an interview and provide both satisfactory references and a Criminal Records Bureau Check (CRB). These checks help to ensure that the staff are suitable to work in the home with vulnerable people and do not have a criminal record, which would make them unsuitable to do so. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 20 All three of the care management survey responses, and all of the relative’s responses confirmed that staff either always or usually have the correct skills and experience for the meeting of service users’ needs. The relative interviewed also confirmed that they felt people have the right skills. Of the seven staff surveys received all confirmed that they had undertaken training in; Moving and Handling, Health and Safety, First Aid, Food Hygiene and Fire Safety. Five had completed training with Medication, two stated it was not applicable to them. In addition other courses attended included; Risk Assessment, The Mental Capacity Act, Multiple Sclerosis training, Care of the Dying Person, The Protection of Vulnerable Adults (POVA), and Violence and Aggression. The registered manager has completed a matrix for the staff training, which identifies the training undertaken by the staff members. In addition staff files contain some certificates of achievement from retraining courses and the staff interviewed confirmed the different courses that they had attended. Having an adequately trained staff team helps to ensure that the staff have the right knowledge and skills to support service users in the meeting of their needs. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is on the whole well managed to ensure that people enjoy a good quality of life, although their involvement in the home’s development could be increased. EVIDENCE: The registered manager has managed the home for some time. She is a registered nurse and confirmed that she has continued to undertake training to be able to retain her registration to be able to practice as a nurse. The registered manager has ensured that the required notifications, for example of a service user having a minor accident/injury have been notified to the CSCI, Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 22 ensuring that the CSCI is aware of incidents and that the management are handling these appropriately. One relative commented’ she is a good manager’. The registered manager has completed a quality assurance audit for 2006, which was forwarded to the CSCI as part of the pre-inspection material. She is currently undertaking similar for 2007. The quality assurance report includes some reference to the service users and their representatives being consulted. However this is mainly on their opinion of the food in the home. The quality assurance system should be developed to consult service users, their representatives and all stakeholders in regard to the home’s success in meeting the aims and objectives of the home. This would help to ensure that all interested parties are involved in the development of the home, in particular for the service users who live there. Service users are supported with their finances. There are individual records and monies are stored safely. Receipts are kept of all expenditure and records are regularly checked for accuracy. Some of the receipts are shared by more than one person; this may cause confusion if an audit was undertaken and the registered manager is to address this. Service users are supported by the home in the meeting of their health and safety needs. Records were seen of up to date maintenance and certificates for Gas and electrical equipment. Hot water is checked both for the correct temperatures to prevent the risk of scalding and for the prevention of legionella. The registered manager confirmed in the pre-inspection material that the policies and procedures are kept up to date, all being reviewed in January of this year, this includes Health and Safety. Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fern Lea DS0000000848.V334960.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N0 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. Standard Regulation 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 OP9 Good Practice Recommendations The registered manager should ensure that people’s medication is handled in a way as to prevent any contamination from fluids and to ensure that people’s medication needs are being fully met. The registered manager should ensure that accurate records are kept of the activities undertaken and declined by service users. This should be individual be able to assess how well peoples leisure needs are being met. The registered person should ensure that service users ability/choice to access communal areas within the home is not restricted. The registered person should ensure that the laundry floor is impermeable to help to ensure the control of infection. The registered manager should develop the quality assurance system to ensure that all stakeholders are fully involved in the development of the home and in the meeting of the aims and objectives of the home. DS0000000848.V334960.R01.S.doc Version 5.2 Page 25 2 OP12 3 4 5 OP19 OP26 OP33 Fern Lea Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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