Inspection on 11/07/05 for Fern Villa

This inspection was carried out on 11th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Fern Villa 21/01/09

Fern Villa 22/01/08

Fern Villa 08/08/07

Fern Villa 19/12/06

Fern Villa 14/06/06

Fern Villa 07/11/05

Fern Villa 20/09/04

Fern Villa 17/05/04

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

CARE HOMES FOR OLDER PEOPLE Fern Villa The Green Ellerker East Yorkshire HU15 2DP Lead Inspector Pam Dimishky Unannounced 11 July 2005 at 9.30 am 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 Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fern Villa Address The Green Ellerker East Yorkshire HU15 2DP 01430 422262 01482 666013 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) Mr Jeremy William Southgate Care Home 23 Category(ies) of OP Old Age (23) registration, with number DE(E) Dementia - Over 65 (23) of places Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2004 Brief Description of the Service: Fern Villa is a care home registered for 23 people over 65 years of age, some of whom may have dementia. Application has been made to the Commission for Social Care Inspection to vary the registration to allow one person under 65 years to reside there. The home is situated in the quiet village of Ellerker which is close to the M62 motorway. It is a converted house with a modern extension which overlooks fields at the back and the village green at the front. The first floor is served by a stair lift for less ambulant residents. There is a small sheltered garden with patio furniture and parking area. The home is privately owned and is generally well maintained inside and out. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6.75 hours (including preparation). The inspector spent some time with the residents and in particular eleven of the 21 were spoken to. A number of records were inspected and a tour of the premises took place. What the service does well: What has improved since the last inspection? What they could do better: The recruitment and selection of staff must improve to ensure the safety of residents. The information kept about staff must also improve. Staff training Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 6 must continue for all staff and updates be planned as part of an ongoing programme. A programme for routine maintenance and renewal of the fabric and decoration of the premises must be produced and implemented with records kept. 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 Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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 Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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) 1,3,4 and 6 Information is available for prospective residents to make an informed choice about where to live. The admission procedure includes a proper assessment being made of residents moving into the service to ensure the home can meet their needs. However, the registered person has not provided confirmation in writing that the residents needs in respect of health and welfare, can be met by the home. EVIDENCE: The home has a welcome pack which is given to prospective residents and a copy is kept in all bedrooms. The pack is made up of the home’s statement of purpose and service user guide. The provider makes an assessment of the needs of all residents before entering the home. However, written confirmation the home can meet their health and welfare needs has not been given to them or their representatives. The home is not registered for intermediate care. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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) 7,8 and 9 All residents have a care plan ensuring their assessed needs are being met and there is evidence of good multi disciplinary working taking place. Until the staff complete their training in safe handling of medicines, and lockable storage is provided for residents who are self-medicating there is the potential to place residents at risk. EVIDENCE: All residents have a care plan which sets out their health, personal and social care needs. One resident said she had been given her care plan to sign. A resident admitted as an emergency for respite a week before the inspection had not got a care plan, but information has been provided by the daughter who is normally the carer; a daily record is being kept of the care provided. The dentist and district nurse both visited the home during the course of the inspection, indicating residents have access to National Health Services to ensure health care needs are fully met. Medications were checked for three residents and found to be in order. One resident has been assessed as able to self medicate but has not been given lockable storage for the purpose. Some medications were being stored in the kitchen in a cabinet, which is not suitable but the manager removed these at the time of the inspection. Seven members of the care staff are attending a Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 10 local college for training in safe handling of medications. Medications returned to the supplying pharmacist for the month of June had not been signed for. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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) 12,13,14 and 15 Residents’ lives are enriched by being able to take advantage of activities provided by the home and to participate in community and family life. Meals in the home are good offering choice and variety according to the wishes of the residents. EVIDENCE: Residents spoke highly of the daily life in the home. A summer fete was noted as being advertised for 16th July and a boat trip on the river at Goole is being scheduled for August; it is planned that all but two or three residents will be going, along with some of their relatives. Examples of other activities taking place in the home include staff talking or reading the newspaper to residents on a one to one basis, playing dominoes or card bingo which is proving to be popular. Relatives and friends visit the home and are happy to help and join in with the activities. One relative had helped the manager to plant up two hanging baskets making the front of the home look very attractive. One lady attends a nearby day centre and was picked up during the morning of the inspection to spend the day there. The library and the church visit the home monthly. Residents gave examples of being able to exercise choice and control over their lives. Although the menu board had not been written up at the time the inspector arrived at the home, it was seen to be completed later in the day. Residents all commented on how good the food is and on the day of the inspection roast Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 12 lamb, potatoes, carrots and leeks were on the menu, followed by jam sponge and custard. One resident said he likes pork and ham and this is often on the menu. Another resident who prefers to stay in her room and has breakfast there, chooses to join other residents for lunch and tea in the dining room. The home displays a Heartbeat Award for food, dated 2002, but this no longer applies. (The inspector was later informed this had been removed and is no longer on display). Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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) 16 and 18 It is evident that residents and their families are happy with the care and services provided by the home. However, information is available should it be necessary to make a complaint. Vulnerable adults policies, procedures and staff training ensure that residents are protected from abuse. EVIDENCE: The home has a complaints procedure which is included in the service user guide given to all residents. A compliments/complaints book is available in the reception area. No complaints have been recorded since the last inspection, September 2004, but many cards expressing grateful thanks for the care given to loved ones are included. Two residents said they had not seen the complaints procedure, and added they have no complaints about the home or the services provided but if they had would speak to the manager. The home has a copy of the East Riding multi-disciplinary guidelines for the protection of vulnerable adults which all staff have read. A video, also on the subject, has been seen by all care staff. The manager has attended a manager’s awareness course provided by social services and has also cascaded this information to her staff. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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) 19,24,25 and 26 The standard of the environment within this home is good and generally provides residents with an attractive, clean and homely place to live. However, improvements are needed to ensure the environment is safe. EVIDENCE: Two residents said they had a lovely room and had been able to bring some of their own furniture into the home; another said “you can’t fault it”. There is evidence of on-going maintenance, refurbishment and redecoration taking place. Two new easy chairs have been placed in the lounge, three bedrooms have new carpets and one lounge, the dining room and three bedrooms have been redecorated. The patio and surrounding flower beds looked tidy and attractive providing a pleasant area for residents to spend their time. The manager and a resident’s relative have planted and hung hanging baskets at the front of the home which is also attractive. Door mats at the entrance to the home and in the corridor of the extension have worn and are presenting a trip hazard. Two toilets did not have soap available for hand washing. Despite the best efforts of the home, one Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 15 bedroom does have an offensive odour and another had a soiled carpet. This carpet is also in need of stretching, but the manager stated the carpet is being replaced. A number of divans are in need of being replaced and radiator covers have not yet been fitted to those radiators which do not have a surface of low temperature, despite the inspector being informed the manager had sourced a supplier at the previous inspection, September 2004. The home has three bathrooms but in practice only one, with a hoist, is used. The temperature of the hot water outlet was reading 47 degrees C and the manager stated she would have this attended to without delay. (Confirmation was later received that the water temperature had been adjusted). The home has a bathing policy displayed in the bathroom and there are also thermometers to check the temperature of the bath water. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 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) 27,28, 29 and 30 The home cannot be sure residents are in safe hands at all times until the home’s recruitment practices improve and training is completed. EVIDENCE: There are currently 22 residents living in the home, although one is in hospital. The staffing levels have not changed from three care staff on duty for the early shift (including the manager), two for the late shift and two at night. The staff are covering cleaning duties as the home has appointed a temporary cleaner for six weeks only, and also cover for the cook on her days off. The manager has no free time scheduled to cover management duties and she is currently trying to recruit a permanent cleaner and cover for the cook to better enable her to do her job. The manager stated at the present time the number of staff on duty are able to meet the residents needs due to the low dependency levels of most residents. One member of the care staff has been recruited since the last inspection. However, much of the information required to be kept by the home has not yet been obtained. Two references have been requested but the manager has had no reply from either. A Criminal Records Bureau check was seen dated 6th August 2004 but these are no longer transferable and does not comply with the current requirements of obtaining a new check before commencing new employment. Five members of care staff employed in the home for some time have also had a Criminal Records Bureau check applied for but these have not Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 17 yet been returned. None of the staff employed in the home, except the manager, have been issued with a contract. There is evidence of improvements in staff training with courses booked at a local college. Seven members of staff are currently attending a course on the safe handling of medicines, the cook is taking basic food hygiene and another member of staff is taking a course in infection control. Two members of staff are booked for nutrition and health, and a further three for infection control and health and safety. Only two members of the care staff have an NVQII qualification and one member of staff is working towards obtaining it. The home will not achieve the recommended standard of 50 of care staff being trained to NVQ level II by the end of this year; a number of the older staff refuse to train as they intend to retire in the near future. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 18 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) 31,33,35 and 38 The management of the home has improved which, in turn, is enhancing residents quality of life and staff morale. Residents views are sought periodically and there is evidence they are able to affect the services provided. The planned improvements in staff training, and the newly installed equipment used by residents, will ensure, in the long term, that the health and safety of residents and staff are promoted and protected but until training is completed there is a potential for residents to be at risk. EVIDENCE: The manager is scheduled to take an NVQ level IV qualification in care and management commencing September 2005. Since becoming manager improvements have been made to the environment, staff training and records kept about the residents. The registered person has been making monthly visits to the home as required by legislation. Residents meetings are held three monthly and minutes indicated their views are being listened to. The home does not keep any monies on behalf of residents. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 19 A new stair-lift was installed in February this year and a new bath hoist in January. The registered person is aware of his responsibilities with regard to complying with health and safety legislation for this equipment. Fire extinguishers were last checked 22nd July 2004 and are due again this month. Records indicate fire alarms and emergency lighting are being checked every week and the manager stated staff are receiving fire training twice a year. Some care staff are booked to attend mandatory training but there is a further need for all staff to be trained and receive regular updates. Someone with a first aid qualification is not available at all times. Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 20 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 3 x 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 x x x x 1 1 1 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 3 x 3 x x 1 Fern Villa J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 21 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 3&4 Regulation 14 Requirement The registered person must confirm in writing to the resident that having regard to the assessment the care home is suitable for meeting their needs in respect of health and welfare Complete the staff training in safe handling of medicines and provide lockable storage for residents who self-medicate The door mats at the entrance to the home and in the extension must be replaced or adjusted to make level with the top of the mat well. Pipework and radiators must be guarded or have guaranteeed low temperature surfaces (This requirement is outstanding from previous inspections). Hot water outlets in areas used by residents must be maintained at a temperature close to 43 degrees C. (The inspector was informed the temperature had been adjusted on the day of inspection). An audit of all beds must be undertaken and a programme implemented for replacements Soap must be available in the Timescale for action On receipt of this report 2. 9 13 On receipt of this report On receipt of this report 31.12.05 3. 19 13 4. 25 13,23 5. 25 13,23 At all times 6. 7. Fern Villa 24 26 16 13 30.6.06 At all times Page 22 J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 8. 29 19 9. 29 19 10. 30 & 38 19 laundry and toilets for the purpose of handwashing to prevent the spread of infection All staff working in the home must have a CRB check, and application must be made for a check for new staff before they commence work in the home. (This requirement is outstanding from previous inspections) Records for staff, which must be kept in the home, must include all the information listed in Schedules 2 and 4 of the Care Homes Regulations 2001. (This requirement is outstanding from previous inspections) Complete the training programme for all staff to ensure at all times suitably qualified, competent and experienced persons are working in the care home. Persons employed by the registered person must receive training appropriate to the work they are to perform and be given suitable assistance, including time off, for the purposoe of obtaining further qualifications (This requirement is outstanding from previous inspections) On receipt of this report 31.8.05 31.12.05 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. 2. 3. Refer to Standard 9 29 31 Good Practice Recommendations Medications returned to the pharmacy must be signed for by the receiving pharmacist or their representative. A minimum ratio of 50 trained members of care staff (NVQ11 or equivalent) should be achieved by 31.12.05. The manager should have an NVQIV in management and care (or equivalent) by 3l.12.05 J53_s19669_Fern Villa_v225599_110705_Stage 4.doc Version 1.40 Page 23 Fern Villa 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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