Inspection on 14/06/06 for Fern Villa

This inspection was carried out on 14th June 2006.

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 07/11/05

Fern Villa 11/07/05

Fern Villa 20/09/04

Fern Villa 17/05/04

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Snydale Care Home

Larchfield Manor

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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 Riding Of Yorks HU15 2DP Lead Inspector Pauline O`Rourke Key Unannounced Inspection 14th June 2006 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 Villa DS0000019669.V300612.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 Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fern Villa Address The Green Ellerker East Riding Of Yorks HU15 2DP 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) 01430 422262 01482 666013 Mr Jeremy William Southgate Mrs Rita McDonagh Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Fern Villa is a care home registered for 23 people over 65 years of age, some of who may have dementia. 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. On 14 June 2006 the fees for the home ranged from £300 to £500 per week dependent on the assessment of need and the room to be occupied. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was carried over 7 hours as part of an annual inspection cycle. In preparation of this visit a pre-inspection questionnaire was sent to the home, at the time of the visit it had not been received by the Commission. The provider did supply the names and addresses of the service users and their representatives. Subsequently questionnaires were sent to 12 service user representatives and 19 service user questionnaires were sent. 4 Service users and 8 representatives responded to the questionnaires. Due to concerns about Fern Villa received by the Commission two additional unannounced inspections have taken place since the last key inspection. Letters sent to the registered person following these visits can be obtained from the CSCI office on request. The inspector looked at all parts of the building, and a number of records were inspected. Ten of the nineteen service users, three of the staff on duty and 5 visitors were spoken with. What the service does well: What has improved since the last inspection? Since the last key inspection and further two unannounced inspections the cleanliness in the home has improved. Staff have received training in adult Protection Issues and they have watched videos covering manual handling and fire training. The service user records have also improved and the information recorded is much more detailed and allows a better picture of the service user they are about. The book that staff used to record whether the service users have had a bath or been to the toilet is no longer kept. The management of Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 6 the medication is much improved and staff have undertaken training in ‘The Safe Handling of Medicines’. 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 Villa DS0000019669.V300612.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 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 the following standard(s): 2, 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are assured their needs will be met if they chose to come to this home. EVIDENCE: The service user files seen during the inspection contained an assessment of need carried out by the proprietor. Where applicable this information was supported by an assessment by a care manager. When it is possible prospective service users and their relatives are encouraged to visit the home prior to any decision being made. However, one relative said that her sisterin-law had been admitted without any consultation. There was no evidence in the service user files that a contract has been provided outlining the terms and conditions of occupancy at Fern Villa. A Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 9 discussion was held with the proprietor’s partner and who thought that copies of contracts are held centrally with the administrator. These contracts should be held on the service user file. Whilst the pre-admission assessments form the basis of the service user care plans the staff have limited access to training to ensure they have the necessary skills to meet the needs of the service users. The home does not provide Intermediate care. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health, social care and personal needs of the service users are met, although they are not always treated with respect and dignity. EVIDENCE: All of the service user files seen contained a care plan. These covered the basic needs of the service users and evidence was seen to show they are reviewed monthly. Service users spoken with were unaware of their care plans or the monthly reviews. Service users should be more involved in the planning of care. The manager has introduced a key worker system and they have to do a monthly report on based on the time they have been able to spend with them in relation to their key worker duties. Staff spoken with said that they were getting used to this new development and were keen to develop this role. Most Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 11 service users spoken with said that staff attended to their needs as quickly as they were able. This feedback was reflected in the questionnaires received by the Commission. The service user plans showed that the service users have access to health services as they required them. The service users spoken with confirmed that they can access the GP, district nurse, optician, chiropodist and where necessary the community psychiatric nurse on request. One service user said ‘always receive prompt attention’ however, one feedback form received said that medical help was not available and the manager is following this up with the individual GP concerned. The administration of the medication was seen to be appropriate and records seen were accurate and up to date. Staff who manage the medication have completed a learning distance course in the safe handling of medicines. There are no service users who currently manage their own medication. The service users spoken with said that the staff always ensure that their privacy is maintained when carrying out personal care tasks and they were all addressed by their preferred name. This was identified in the service user plan. Visitor’s feedback also indicated that any visits they made could be done in private. During the inspection staff were overheard addressing the service users at times in a way that did not protect their privacy or show respect. This happened at times when the staff were busy or service users wanted extra support. Induction training now covers the importance of treating service users with dignity and respect at all times and staff should also be reminded of this through regular supervision. This detracts from the quality of care given. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The service users are able to keep their own routine within the home and join in with social activities. EVIDENCE: Service users spoke highly of their daily life in the home, the staff and the manager. They are able to exercise choices in their daily living routine and staff are supportive in the decisions they make. The bedrooms had been indivualized by the service users with their own furniture. There are activities available everyday and the service users spoken with particularly enjoyed the musical sing-a-longs, dominoes and the organised excursions. There is a monthly church service and a communion service in the home for the service users. Visitors were in and out of the home all day and staff clearly knew who they were and who they were visiting. The service users spoken with said that their visitors were always made welcome and there were not restricted to when they Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 13 came. Visitors spoken with during the visit and feedback received said that they were always welcomed, could visit in private they are offered refreshments and kept informed of important matters. Staff spoken with said that they would support service users if there was someone they did not want to see on a visit. At the time of this inspection there were no planned menus with the main meal being decided on the day prior to its preparation so that something could be taken form the freezer or obtained from the local butcher. A record is kept of the meals provided and an alternative is provided rather than a direct choice. There are no special diets required at this time. The cook has had no formal training but she is experienced at providing a traditional menu. A menu should be developed in conjunction with advice from a dietician and input from the service users. The menu should be displayed on a daily basis showing any alternatives offered. The service users said that they enjoyed their lunch and the meal seen was well presented. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Complaints and concerns are dealt with and staff are aware of adult protection procedures, but safety of service users is potentially compromised by poor recruitment practices. EVIDENCE: The complaints procedure is contained in the Service User Guide and there was a notice on the public notice board. Service user spoken with said that if they had any concerns they would take them to the manager. The visitors spoken with also said they would take any concerns to the manger and were confident that she would deal with them appropriately. The Commission recently received a complaint and the manager was asked to investigate it. The further information received by the Commission indicated that it had been dealt with in a satisfactory manner. The complaint was not substantiated. There was no evidence that this policy has been reviewed recently. The home has a copy of the East Riding multi-disciplinary guidelines for the Protection of Vulnerable Adults. The staff spoken with said that they had read the policy and this had been backed up by watching a training video. Staff spoken with said they would report any allegations of abuse to the manager or the proprietor. The manager has attended a manager’s abuse awareness course provided by social services. However the poor recruitment practice does not ensure the service users are protected from inappropriate staff. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The environment meets the needs of the service users but could be improved. EVIDENCE: All areas of the environment seen were clean, well maintained and reasonably decorated with the exception of two rooms where the carpets required either stretching or replacing. These rooms were identified to the manager during the inspection. There is a fire risk assessment in place although there were no written environmental risk assessments the manager was aware of where the risks were in each of the communal areas. A number of divans are in need of replacement and no progress has yet been made towards a requirement made at the last inspection for a programme to be implemented for replacements; at Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 16 the last inspection the timescale for completion was agreed for 30/06/06; the manager has obtained a stock of valances to be put on the beds in the interim. The staff assist with the laundry and general domestic chores. They should all receive training in COSHH so that they are aware of the products used within the home. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There are insufficient staff. EVIDENCE: The rotas seen show that there are usually three care staff on duty each morning and two staff on duty during the evening and over night. However the manager has been included in these figures. Staffing shortages have meant that there are sometimes only two staff on a morning. The staff not only carry out the caring tasks but also the domestic tasks required in the home. This means that ‘jobs get done’ but it also means the time available to the staff to spend with the service users becomes limited. The manager needs to be supernummary to the care staff and it is recommended a dedicated domestic member of staff be employed. Feedback received from relatives said that ‘I feel a cleaner is necessary to keep on top of things as the staff could spend more quality time with the service users who need more stimulation at times. There was no evidence to suggest that the staff are supported in obtaining National Vocational Qualifications. Training provided is primarily done so internally and limited to basic topics, any external training is done so through Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 18 Learning Distance Courses which are provided free of charge. There was one course advertised covering the topic ‘diabetes’ and was provided by a local health worker. However there was no evidence to suggest which members of staff were going on this course. The recruitment process is poor with shortfalls in the process. The staff files seen were incomplete and whilst the manager said that staff were in the process of applying for a Criminal Records Bureau disclosure there was no evidence to support this. Written references are not always obtained and some files did not have a completed application form. There were no job descriptions available or contracts of employment held in the staff file. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The quality of care would be improved if the manager had more time to guide staff and meet standards. EVIDENCE: The manager is newly registered and has just started her National Vocational Qualification level 4 in the Management of Care. Since she started there has been an improvement in the service user records, however she needs to now concentrate on the staff records, which were incomplete. As manager she has had to work as a care assistant and a cook due to staff shortages this has meant that the administration element of her role has been neglected. She Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 20 should be supernumerary to the care staff to allow her the time she requires to undertake the management role. Service users spoken with said that she always had time for them. Staff spoken with also said she was supportive and always available to them. The feedback received from the relative questionnaires also said she was available and approachable at all times. Service user meetings are held quarterly with minutes kept and the proprietor is keeping a record of quarterly audits he undertakes. It is clear the manager listens to the views of the service users and where possible takes appropriate action. The home does not keep any monies on behalf of service users and is not involved in their financial affairs. The registered provider makes monthly visits and provides the Commission with regular reports, however the information does not reflect accurately what goes on in the home. A complaint investigated recently identified the home was not cleaned to a high standard, this complaint was upheld at the time and the standard has improved since then but the registered provider should have identified this issue as a result of his monthly visits. There is a health and safety policy in the home but there was no evidence that staff have been made aware of it. Whilst staff have an understanding of Infection Control they have received no training in COSHH, Food hygiene, or First Aid. There were no electrical or gas safety certificates available although there was evidence to show that the hoists and bath lift had been recently serviced. A record is kept of accidents, although staff should always use the full name of the service user involved and not just their first name. The records should be removed from the accident record book and stored separately until they have been seen at an inspection then they should be files in to the individual service user file. Not all accidents requiring attention from one of the emergency services have been reported to the Commission. Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 3 10 2 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 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Fern Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP7 Regulation 15 12(4)a Requirement Timescale for action 30/10/06 OP10 3. OP19 13(4) Service users should be included and involved in the care planning and reviewing process. The staff must ensure that they 30/10/06 treat the service users with respect and dignity at all times and not disclose personal information in a public environment. The registered manager must 30/10/06 ensure that environmental risk assessments have been carried out. The carpets identified to the registered manager during the inspection must either be stretched or replaced to prevent a tripping hazard. An audit of all beds must be undertaken and a programme implemented for replacements. (A requirement from the previous inspection with a timescale of 30/06/06) More staff must be recruited to allow care staff more time to spend with service users and to free the manager to do her duties DS0000019669.V300612.R01.S.doc 16(2) 4. OP24 16 30/10/06 5. OP27 18 (1) 30/10/06 Fern Villa Version 5.2 Page 23 6. OP29 19 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 working 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) 30/10/06 7. OP30 18 All staff musty receive health and safety training to assist them to carry out their duties safely including the following topics: • COSHH • First Aid • Food Hygiene • Health and Safety. 30/10/06 8. OP31 9(2) 18 They should also receive training in National Vocational qualification level 2 and in subjects relating to the ageing process. The registered manager must 30/10/06 inform the Commission when she has completed her National Vocational qualification level 4 in the management of care. The registered provider must ensure that the registered manager has the time off rota needed for her to ensure that all the records as required by the Care Homes Regulations 2001.Schedule 4 can be properly and fully maintained. The registered provider must DS0000019669.V300612.R01.S.doc 9. Fern Villa OP38 13 30/10/06 Page 24 Version 5.2 23(2)c supply the Commission with the following safety certificates: • PAT electrical equipment certificate • Gas safety certificate • Electrical safety certificate. 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 Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Villa DS0000019669.V300612.R01.S.doc Version 5.2 Page 26 - 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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