Inspection on 03/01/06 for Fern Lodge

This inspection was carried out on 3rd January 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fern Lodge 03/12/07

Fern Lodge 15/01/07

Fern Lodge 19/10/04

Fern Lodge 25/06/04

Similar services:

Claremont House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Firstlings

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Fern Lodge 108 Broad Road Bocking Braintree Essex CM7 9RX Lead Inspector Gaynor Elvin Unannounced Inspection 3rd January 2006 09:30 Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 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 Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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 Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fern Lodge Address 108 Broad Road Bocking Braintree Essex CM7 9RX 01376 550432 01376 342928 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) Braintree Health Care Limited Mrs Jennifer Woolliams Care Home 8 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (1), Learning disability (8), Learning disability of places over 65 years of age (8) Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) Persons of either sex, aged 65 years and over, who require care by reason of a learning disability (not to exceed 8 persons) One person, over the age of 65 years, who requires care by reason of a learning disability and dementia, whose name was made known to the Commission Three persons, under the age of 65 years, who require care by reason of a learning disability and dementia, whose names were made known to the Commission The total number of service users accommodated in the home must not exceed 8 persons 26th May 2005 5. Date of last inspection Brief Description of the Service: Fern Lodge is a care home registered to provide accommodation, personal care and support to eight people; of either sex, under the age of 65 years and over the age of 65 years, who have a learning disability. The home is owned by Braintree Healthcare Ltd, and the Registered Manager is Mrs Jenny Woolliams. Fern Lodge is a purpose built bungalow situated in pleasant secluded surroundings, in a semi rural location on the outskirts of the town of Braintree, in the county of Essex. All bedrooms are of single occupancy and offer spacious accommodation with a small lounge area, kitchen facilities, en suite bathrooms and patio access to the garden. The home also has a dining room, lounge and an attractive garden with garden furniture. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on one day in January 2006, over five hours. Fern Lodge is registered to accommodate service users, under and over the age of 65 years, who require care by reason of a learning disability. Since the last inspection a variation to the current condition of registration was applied for and agreed by the CSCI, to enable the home to continue to provide care to those individually named service users with changing needs related to dementia, as long as their assessed needs can be met. During this inspection, it was agreed with Mrs Wooliams, the Registered Manager, that Fern Lodge would be best assessed against the mixed category National Minimum Standards and intended outcomes to reflect the wide range of needs met by the service. All of the key standards and the intended outcomes have been assessed in relation to this service during at least two inspections for the current inspection year (April to March). To view the assessment of standards and outcomes not included within this report, please refer to the previous published report dated 26th May 2005. What the service does well: What has improved since the last inspection? Prior to the inspection the Commission had received a revised Statement of Purpose and Service User Guide to meet a requirement made in the previous inspection report. These documents contained the appropriate information about the services and facilities provided by the home to enable prospective service users to make a choice. The home had made significant progress towards NVQ training: the Registered Manager had successfully completed NVQ level 4 in care and management (Registered Managers Award), ten care workers had successfully completed NVQ level 2 or 3 and the remainder of the staff were all working towards completion. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 6 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 Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards 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 The service operates a responsible pre admission assessment process and care and attention is given to ensuring appropriate admissions. The care home demonstrated that the service was able to meet the assessed needs, including changing needs, of the current service users accommodated at Fern Lodge. EVIDENCE: The Statement of Purpose was reviewed on this occasion and had been updated to meet a requirement identified at the last inspection. The document reflected the aims and objectives of the service and informed prospective service users of the services and facilities offered. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 9 The file of a new service user contained a completed Care Management assessment and an Occupational Therapy and Physiotherapy assessment carried out prior to admission. The service user also confirmed they had visited the home prior to admission. The home provided aids and equipment appropriate to support the care needs of the service users. There was evidence of a good level of staff training to promote good care practice and enable staff to develop the skills required to meet the assessed needs of the service users accommodated. Staff demonstrated an awareness of specific communication needs and channels with the service users, providing support and encouragement enabling them to make choices throughout their day. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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 & 10 Individual plans continue to require further development, particularly in relation to person centred planning, ensuring clearer identification of a persons support needs. The homes review process needs to be more regular and would benefit from improvement in terms of evaluation to ensure the best way assessed support needs can be met for optimal development and focus on outcomes. EVIDENCE: The home runs two specific programmes of care within the one service: support towards a more independent lifestyle for the younger adult and care and support for the older person with changing needs due to the ageing process. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 11 The sample of care plans examined varied in content. Some contained good detailed information utilising risk assessment and risk management strategies, and one in particular which related to mobility and behaviour problems. One service user indicated there was a possible opportunity to move into a more independent service provision. The care/support plan for this individual did not reflect their support needs nor did it include review, monitoring or evaluation to assess a clear progression towards outcomes for future planning. Residents are consulted with regard to the running of the home through regular resident meetings and one to one consultation for those with limited communication. Policies and procedures were in place with regard to confidentiality, including reference within the staff handbook, to guide staff on practice. One member of staff had produced a leaflet on confidentiality issues as part of their NVQ assessment and this leaflet was also available within the home. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) 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, 16 & 17. Opportunities were given to access the nearby community and service users were supported to participate in activities, which are age appropriate and according to their preference, contributing to a fulfilling lifestyle. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 13 Daily routines were flexible and there was a strong ethos in the home of promoting service users’ independence and choices. Nutritious meals were served in a happy, relaxed atmosphere with staff assisting sensitively where required. EVIDENCE: Fern Lodge caters for a wide varying level of dependency and need, including needs associated with the older person. Some of the current service users are not of an age to seek employment or further education and a more relaxed lifestyle was respected for those individuals. Arts and craft, history and music and movement sessions were held within the home, weekly, by the local adult college to stimulate thought and expression, encourage group participation and promote exercise and mobility. Staff spoken with felt the home was in tune with an ordinary lifestyle for the service users and offered opportunities for the service users to access the community and participate in chosen leisure activities individually or as a group; shopping, lunch or coffee outings, cinema and bowling. Festive and anniversary occasions were celebrated. Service user’s spoken with were satisfied with the type and level of activities available and with the quality of life they had. Most service users participated in menu planning and shopping and were supported in a balanced approach to healthy options. Meals were prepared and cooked by the care staff and the more independent service users were given the opportunity to assist, with support. One service user said they liked to prepare the vegetables and had peeled and chopped the onions for the casserole being prepared for the evening meal, however this was not reflected within a support plan. The main meal of the day of the inspection was balanced and looked and smelt appetising. Service users had the choice of taking their meals in the dining room or in their own rooms, which includes a lounge/sitting area. Two service users were observed having their evening meal together and said they took turns to dine in each other’s rooms and how much they enjoyed this arrangement. All the service users ate Sunday lunch together in the dining room. Breakfast was taken in their rooms and some were supported to make their own toast, drinks and cereal. Records of diet and fluid intake were kept for monitoring of well-being. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 14 Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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 & 21 Staff engaged positively with the service users and demonstrated a good understanding of the service users they were supporting, respecting their privacy and dignity. Service users were protected by robust policies and procedures for dealing with medicines and staff handling medication had received and completed appropriate training. EVIDENCE: Staff were observed to be respectful and helpful in their approach to the service users and were accessible to the service users at all times throughout the inspection. Service users spoken with said the staff were kind and helpful. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 16 In the sample of care plans examined, records of physiotherapy assessments and moving and handling risk assessments were evident although not all were dated or provided evidence of review. Individual care programmes were agreed and tailored to needs related to personal care, mobility and social but did not reflect emotional, psychological or health needs or how these were being met. From discussion with management and staff it was clear that care needs were known and being met although documentation did not reflect this. Staff were observed to provide care with sensitivity to the more frailer service users with high care needs. Discussion with staff indicated that they were fully aware of the physical healthcare needs of the service users and any changing needs were promptly addressed. Appropriate pressure relieving equipment was in use for those service users with limited mobility, and preventative pressure sore care and management was observed. Service user’s medication was stored within locked cupboards in their own private accommodation. The current service user’s did not retain, administer or control their medication and required support and assistance. A policy and procedure for the safe receipt, recording, storage, handling, administration and disposal of medicines were in place for staff guidance and staff had received appropriate training ensuring appropriate knowledge and skills for safe practice and responsibility in medication administration. Medication was dispensed by the local pharmacy into Monitored Dose Systems (MDS). Medication Administration Record sheets (MARs) examined were dated and signed appropriately. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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 Satisfactory arrangements were in place to promote the protection of service user’s from abuse and for responding to their concerns. Complaints were responded to and dealt with appropriately. EVIDENCE: A complaints policy and procedure was in place. The CSCI had received an anonymous concern related to a health and safety issue regarding an operational procedure within the workplace. The concern was passed to the home to investigate and was dealt with appropriately in line with policy and procedure, with detailed records of action taken and outcome. The complaint was not upheld. An Adult Protection policy and procedure, including Whistle Blowing, was in place, which ran in conjunction with Local policy and Department of Health ‘No Secrets’ guidelines: to guide staff of the steps to be taken in the event of an allegation or suspicion of abuse being reported. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 18 In addition to formal training, enthusiastic and innovative staff members had given a presentation to the rest of the staff team, on abuse issues, including role-play, and this was assessed by an NVQ assessor. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) 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, 27, 29 & 30. The premises were in keeping with domestic style living arrangements and equipped to meet the service users’ assessed needs and lifestyles. Fern Lodge created a comfortable, homely and safe environment and areas seen were cleaned to a high standard. Individual bed/sitting rooms enabled the service users to express their individuality and promote independence. EVIDENCE: Fern Lodge is a purpose built building, meeting National Minimum Standards with regard to private and communal space, bathroom and toilets. Individual Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 20 accommodation was decorated and furnished to a high standard, personalised to each individual and offered en suite facilities, a private sitting area, a kitchenette and access to the garden. A sensory area, made up of various coloured lights and textures is set up at each end of the hallway to distract and stimulate those service users with dementia. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36. Staffing levels were appropriate to the needs of the service user’s and staff were aware of their roles and responsibilities. Staff training is provided in a planned way, to ensure understanding, knowledge and skills are developed to meet the general and specialised needs of the service users. Record keeping and supporting documentation relating to recruiting processes and practices was poor and did not provide evidence of robust procedures carried out to protect service users. A variety of supervisory processes were carried out to support staff but a stronger emphasis on formal recorded supervisions is required to enable staff to reflect and develop own practice. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 22 EVIDENCE: The ratios of care staff to service users were determined according to service users assessed needs calculated by the Residential Forum, a tool recommended by the Department of Health. Staff spoken with enjoyed working in the home and demonstrated a good understanding and commitment to the service users within their care. They were aware of their individual roles and responsibilities and felt they received good support and development opportunities from the management. Ten of the twenty-two care workers had successfully completed NVQ level 2 or 3 and the remainder of the staff were all working towards completion. The home plans annually for training requirements including update in mandatory areas and training specific to meet service users needs. Eight staff are currently undertaking a pilot Level 2 accredited modular course in Dementia Care at Chelmsford College, incorporating induction and foundation underpinning the essential elements of dementia care. The sample of staff files examined varied in content and did not contain all the information required by regulation with regard to identification, previous experience, employment history and two references. All files contained a copy of the contract of employment, grievance and disciplinary procedure but did not have an equal opportunity policy. Original copies of Criminal Records Bureau (CRB) disclosures were not on files or available for inspection. The Manager has a hands on approach to managing the home, frequently working alongside care staff; staff therefore received regular practical supervision through daily contact. Staff meetings also provided additional opportunities to discuss concerns or care related issues. Progress has been made with formal individual recorded supervisions, however these need to be more frequent and fully documented to reflect all the elements necessary to support staff in developing and sustaining their working practice. Staff files examined did not contain a record of regular supervisions carried out. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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, 41, 42 & 43. The home is managed efficiently and in the best interests of the service users and staff. Overall the health, safety and welfare of the service users are promoted and protected. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 24 EVIDENCE: The Registered Manager, Mrs Wooliams, has successfully completed NVQ level 4 in management and care (Registered Managers Award) and is currently undertaking the modular Dementia Care course. Mrs Wooliams demonstrated a sound knowledge base and an understanding of the service users psychological, physiological and healthcare needs. A commitment to training and development was evident and there was clear evidence of progress in achieving the homes aims and stated purpose. The home had begun to address quality assurance and quality monitoring by the implementation of stakeholder, service users and relative questionnaires. However no further action had been taken to develop a framework to demonstrate evaluation, action and review of questionnaire responses to measure and maintain delivery of care and quality outcomes for service users and inform future planning. Records required by regulation for the protection of service users inspected on this occasion included a sample of: staff rotas; staff recruitment records; service user assessments, care plans, and daily care records (including weight monitoring and food and fluid intake); medication; and menus. Where relevant, records have been commented on under the relevant standard, but were generally poorly maintained. The Manager acknowledged that work was required in this area to reflect the care being carried out within the home. Health and safety records relating to current inspection and testing of hoists, gas boiler, gas safety certificate, electrical installation and environmental health certificate were evident. Fire safety records indicated that fire drills had taken place on a regular basis; fire alarms, emergency lighting and extinguishers had been inspected and serviced for the current year. Fire safety risk assessments had been carried out on all areas of the premises and action was specified to reduce any identified risk. A fire safety inspection had been carried out by the Essex Fire Safety and recommendations implemented. The homes fire safety policy and procedure required updating to reflect these recommendations. A competent and accountable internal and external management structure was evident. The home complies with the conditions of registration and a variation to the condition of registration has been agreed by the CSCI to continue to provide care and accommodation for those named service users presenting with varying levels of cognitive impairment, as long as the home is able to meet those needs. A current Employer Liability insurance was on view. Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 25 Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 3 4 3 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 4 26 4 27 4 28 X 29 4 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 4 38 3 39 2 40 X 41 2 42 3 43 3 2 3 X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fern Lodge Score 3 2 3 3 DS0000017715.V281472.R01.S.doc Version 5.1 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 OP7YA6 15 Regulation Requirement Timescale for action 01/04/06 OP8YA19 2. 12 3. OP29YA34 OP37YA41 Sch2 7,9,19 Sch 3 17 4. OP36YA36 18 (2) The Registered Manager must ensure that individual care plans reflect levels of dependancy and support required by the service user to meet their needs within a person centred programme approach, which are reviewed on a regular basis. The Registered Manager must 01/04/06 ensure individual care plans reflect healthcare needs and that potential health risks are assessed and appropriate actions in place to reduce them are recorded. The Registered Manager must 01/04/06 ensure records and documentation required by regulation for the protection of service users and for the effective and efficient running of the service are maintained and in good order. The Registered Manager must 01/04/06 ensure staff have regular recorded supervision meetings at least six times a year in addition to regular day to day contact. DS0000017715.V281472.R01.S.doc Version 5.1 Fern Lodge Page 28 5. OP33YA39 24 This is a repeat requirement not met within timescale 1st September 2005. The Registered Manager must implement an effective quality assurance and continuous self monitoring system to measure outcomes and inform future practice. 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fern Lodge DS0000017715.V281472.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Lodge DS0000017715.V281472.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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