Inspection on 19/12/06 for Fern Villa

This inspection was carried out on 19th December 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 14/06/06

Fern Villa 07/11/05

Fern Villa 11/07/05

Fern Villa 20/09/04

Fern Villa 17/05/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Fern Villa The Green Ellerker East Riding Of Yorks HU15 2DP Lead Inspector Mr Tom Tomlinson Key Unannounced Inspection 19th December 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.V321575.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.V321575.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.V321575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 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. 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. This was dependent on the assessment of need and the room to be occupied. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second ‘key inspection’ undertaken by the Commission for Social Care Inspection at Fern Villa during the last twelve months. This was considered necessary due to the number and seriousness of the Requirements made during the previous inspection. The inspection visit consisted of discussions with the registered manager and the staff on duty. Discussions were also held with the more able service users on both a group and individual basis. Reliance was placed on observing the less able service users, particularly their interaction with the staff. Discussions were held with visiting relatives of service users and a visiting medical practitioner. An inspection of the premises and an examination of a number of statutory records were also undertaken. Comment Cards were sent to a number of health and social care professionals but none were returned. The report also incorporates information received by the Commission for Social Care Inspection prior to the inspection visit. Whilst this inspection looked at all the key standards, it also concentrated on the requirements and recommendations made during the previous inspection visit. What the service does well: It was apparent from discussions with the service users and their relatives that the home provides a relaxed and informal environment in which the service users can live their lives at their own pace. It was evident that a close relationship exists between the service users and the staff with comments from service users such as, “The staff are super”; “I’m all right, they (staff) help me” and “If I didn’t like something, I’d say so to the staff”. Comments from visitors to the home included, “I’m absolutely pleased. He (service user) gets personal attention – he gets better care than I could give. I’m kept informed by the staff and the records are available to me and my (service user)”; “Fern Villa is absolutely brilliant – we looked at nineteen homes before deciding on Fern Villa. We knew it was right as soon as we walked in. The staff work hard”; “The staff do a fine job. The manager is always approachable and friendly” and “I think that the service users are well looked after – the staff are caring”. It should be noted that in spite of the concerns raised in the body of the report, such as the level of staffing, the general view of the service users and their relatives was that the staff in the home provide a good quality of care. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Fern Villa DS0000019669.V321575.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.V321575.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is adequate. Pre-admission assessments undertaken on prospective services users enable the registered manager to make a considered decision as to the appropriateness of a proposed placement in the home. The lack of additional information available to the registered manager, such service users’ Contracts of Residence and the scale of charges, could undermine her professional credibility. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All new service users had been provided with an Information Pack that incorporated the Service Users’ Guide. Relatives of the service users confirmed this. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 9 The service users’ records provided confirmation that pre-admission assessments had been undertaken on prospective service users to ensure that the home had the capacity to meet their needs. The assessments formed the basis of the initial care plan for the service users. The registered manager demonstrated a good awareness of the need for a comprehensive preadmission assessment. Those service users spoken to could not recall the assessment although some of their relatives said that they could. As the manager does not have a car, the Registered Provider had done several of the pre-admission assessments. The home’s Administrator, who was located in Lavender House in Brough, dealt with most of the admission process and maintained the records of the correspondence relating to the process. For example, there were no copies of the service users’ contracts or terms and conditions of residence available at Fern Villa, the registered manager did not have access to the scale of charges (fees) and there was no copy of a letter providing confirmation to a prospective service user that the home was able to meet their needs. Fern Villa DS0000019669.V321575.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. The service users’ care plans provide the staff with adequate information on which to base the care required. The standard of care was largely dependent upon the availability of staff and the service users’ needs at any particular time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users had been provided with a care plan that had been based on their initial assessment. The care plans that had been developed by the registered manager were in addition to, but compatible with, the care plans provided by a placing authority. This ensured consistency in the provision of care. Three care records were examined as a part of the case tracking process. The care plans clearly identified the primary needs of the respective service user and the action to be taken by the staff in order to meet those needs. The care plans incorporated risk assessments. Evidence was Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 11 provided to confirm that a copy of the care plan was also provided for the service user and/or their representative who was generally a family member thereby involving them in the process. Those care plans examined had been signed in agreement by the service user’s representative. Those service users spoken to were not aware of their care plans and stated that they had no interest in being involved with them. In some of the care records examined, changes had been identified to a service user’s needs during the review process but these changes had not been reflected in the respective care plan. For example, one service user’s mobility had deteriorated. Action taken to address these changes in need had been recorded. The manager was responsible for developing and updating the care plans with input provided by the respective Key Worker. There was recorded evidence that the care plans had been reviewed monthly by the registered manager. Where a review of a service user had been carried out by Social Services, it had incorporated the report provided by the Key Worker. There was also recorded evidence in the care records that the Key Workers regularly spend ‘quality time’ with the service users on a one-to-one basis. This included having personal conversations in the privacy of the service users’ rooms. This enabled the Key Workers to continually assess the service users and bring any changes in need promptly to the attention of the manager. The service users were provided with one bath a week unless circumstances dictated otherwise. The frequency of bathing appeared to be dependent upon the availability of staff and the needs of the service users. Baths were generally only provided when there was a minimum of three staff on duty. The staff stated that two service users had a bath each morning and one in the afternoon. Although a number of service users were incontinent, there was no physical evidence of this. According to the staff this was due to good toileting programmes. This was reflected in the respective service users’ care plans. The care records provided evidence that the service users had good access to health and social care professionals. A General Practitioner visited the home weekly and members of the Community Healthcare Team also made frequent visits. A visiting healthcare professional commented, “ I think that they (service users) are well looked after. The staff are very caring. In the circumstances they cope quite well. I mean that limited numbers of staff can only do so much. It’s OK when the manager is here as she knows what is going on”. (See Staffing and Management Standards). There was no evidence of formal nutritional screening of the service users although the registered manager and the cook were aware of the need to ensure that the service users receive a balanced and nutritious diet. The records confirmed that the service users had been regularly weighed although Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 12 this could only be undertaken with those service users who were weight bearing, as the home did not have sit-on scales. One very elderly and frail service user was bed-bound. According to the staff and a visiting General Practitioner (G.P.) this service user was supported through visits by District Nurses and did not require any nursing intervention to be undertaken by the home’s staff. The G.P. commended the care provided by the staff of Fern Villa. On the day of the inspection visit the service users were well groomed and dressed in clean and appropriate clothing. From observation of the staff it was apparent that they had established a close relationship with the service users and provided support in a caring, patient and respectful manner. It was noted that some of the service users were addressed by the staff using terms of endearment such as ‘darling’ and ‘my love’. Those service users spoken to did not object to this although care must be taken by the staff to ensure that such terms do not inadvertently undermine the dignity of the service users or become used in a patronising sense. The home continues to use a Monitored Dosage System for administration of the service users’ medication. Some medication was, however, administered from a bottle or original container. The medication was appropriately secured and only nominated staff who had received training had access to it. From a description of the process it was evident that the administration process was appropriate and minimised the chance of error. For example, two staff administered it and it was given directly to the respective service user. No Controlled Drugs were being used. None of the service users had been accessed as being capable of self-medicating. The medication records were complete and up to date. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. The service users are provided with a range of group activities that included the services of external entertainers thereby providing occasional stimulation for the service users. The service users present as having a diverse range of needs but due the limited staffing available it is difficult for the staff to meet individual’s social needs and wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was recorded evidence, supported by the more able service users that they were provided with an opportunity to participate in a range of social activities within the home. In general these were group activities that included the involvement of visiting entertainers. Those service users spoken to said that they had the choice as to whether or not to join in the activities. Activities were often provided on an ad-hoc basis to take into account the needs and wishes of the service users at a particular time as well as the availability of the staff (See Staffing). Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 14 A number of the service users spent most of their time in their rooms. According to them this was by choice. One service user was bed-bound and was supported through regular visits by healthcare professionals. The majority of the service users spent their time in the main lounge. Whilst it was the assertion of the manager that the service users preferred this, it was apparent from observation that this was also for the benefit of the staff to enable them to supervise the service users. It was noticed, for example, that when a service user left the lounge they were encouraged to return to it by the staff. This arrangement was apparently considered necessary as the care staff were also required to undertake domestic tasks such as cleaning and washingup thereby further reducing the number of available staff. (See Staffing). Several of the more frail service users looked somewhat apathetic and were reluctant, or unable, to hold a meaningful conversation. One of the more able service users said that they preferred their own company as several of the service users had dementia and were not particularly sociable. It was observed that the service users could have visitors at any time of the day and that the visitors were made to feel welcome by the staff. This was confirmed by a visitor who said that they were invariably offered refreshments by the staff. Comments from relatives of service users included, “ I’m absolutely pleased (service user) has settled in well. (Service user) gets personal attention. I’m kept informed by the staff and the records are available to me and my (service user)”; “Fern Villa is absolutely brilliant. The staff work hard. They are shortstaffed sometimes, as they can’t get people from agencies. I would recommend it (Fern Villa) to anyone. I was taken around the home and introduced to all of the clients. We go a lot and we are always made to feel welcome” and “The staff do a fine job. There was a lack of cleaning at one point and it (Fern Villa) did smell a bit. I spoke to the manager about it – she didn’t seem to mind. (Service user) sometimes grumbles about the food. Sometimes they are a bit short staffed. I am a bit concerned about a resident who occasionally wanders all night and goes into my (service user’s) room. They are considering fitting alarms to deal with this. The manager is always approachable and friendly”. There were a considerable number of complimentary letters from relatives of service users expressing their thanks for the service provided by the staff. The home had two cooks to cover all days of the week. The cook on duty provided examples of the menus. These appeared to be reasonably varied and provided a balanced diet. There were no planned choices of meal but assurance was given by the staff that a choice would always be available should a service user not like the one on the menu. Those service users spoken to did not know what was for lunch. The dining room was furnished and decorated to a good standard. The service users were sat four to a table. The tables were enhanced by the use of table-decorations and the use of tablecloths and napkins. The meal was a social occasion with conversation Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 15 natural and spontaneous. The service users indicated their satisfaction with the quality of the meals. Some of the service users had chosen to have their meals in their rooms. The care staff on duty served the meals. This was done with patience, respect and good humour. The meals were plated-up although the service users were asked what size of meal they wished. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. The service users’ welfare is protected through a good level of internal and external support and monitoring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an appropriate complaints procedure that was readily accessible to the service users and visitors to the home. It was also included in the information pack provided for all of the service users. It was evident that the service users and their relatives were confident enough to raise concerns and issues with the manager without necessarily having to go through the formal complaints procedure. The staff had received training in Adult Protection procedures and from discussions with them it was evident that they had a reasonable understanding of the types and indications of abuse. The level of internal and external support provided for the service users should ensure that any problem or issue would be quickly identified and acted upon. A relative of a service user provided an example of this. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. The service users are provided with a comfortable environment in which they can live their lives at their own pace. Having rubbish and discarded furniture left in the garden undermines the general standard, and particularly the aesthetic quality, of the premises. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection visit the home was decorated in preparation for Christmas. It was warm, clean and in general reasonably maintained. It was noted, however, that in one bedroom the wallpaper had become detached around the window and a corridor carpet on the first floor was frayed and could become a tripping hazard. It was evident that the service users had Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 18 been encouraged to furnish their rooms with their personal belongings thereby promoting a degree of domesticity. Some of the service users had brought pieces of furniture into the home. The furniture provided by the home was matching and appropriate. The bedrooms were numbered and displayed the name of the occupant on the door. The bedroom doors were not lockable as the locks fitted were of an inappropriate design. Some of the call points had extensions fitted, such as a tie, to ensure that the service users could operate the call system when sitting in a chair. This looked rather amateurish and inappropriate. One bed had rails fitted. These had been risk assessed, were properly fitted and their use agreed to by the service user’s family in writing. The hot water outlets had control valves fitted to ensure that the temperature remained within safe limits. Two outlets were tested and proved to be satisfactory. The manager confirmed that the Registered Provider made regular checks of the hot water temperature but these had not been recorded. Consequently there was no verification that these checks had been carried out. Since the previous inspection some of the furniture in the communal areas/bedrooms and many of the beds had been replaced. The old furniture had been left in the garden areas awaiting disposal. This was very unsightly and could, it was suggested, attract vermin. The manager had undertaken an audit of the beds and fourteen, according to the Responsible Individual, had been replaced. It was observed that several of the service users, particularly those who used walking frames, had difficulty in using the fire doors leading to the lounge. This was obviously frustrating for these service users. The home had a stair lift in lieu of a passenger lift in order to provide the service users with access to the upper floor. The service users could only use the stair lift when assisted by a member of staff, which again further diluted the number of staff available at any given time. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. The number of care staff available limits the standard of the service provided. The lack of care staff has a detrimental effect on the ability of the manager to undertake her specific managerial tasks. There was a lack of evidence that some staff had not been appropriately vetted thereby potentially putting the service at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection visit there were four staff on duty. These consisted of the registered manager, two care staff and a cook. A cleaner was available for two days a week. The staffing roster confirmed that in general there were three care staff available in the morning and two in the afternoon. In most instances the care team included the registered manager. Comments received from service users, their relatives and a visiting Healthcare Professional confirmed that there were times when the home was short-staffed and the staff on duty ‘stretched’. This was also underlined by the registered manager who said, “ I’ve had problems updating the paperwork because I spend most of my time doing hands-on care. I don’t mind as I enjoy doing it”. There was no specific evidence that the manager had delegated tasks to the Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 20 staff or a deputy. Given that the home had eighteen service users two of whom required the assistance of two staff, up to ten were incontinent and one bed-bound, it was evident that the staffing level was not adequate to fully meet the needs of the current service users. This situation was further complicated by the fact that the care staff were required to do some cleaning and washing up and assist service users to use the stair lift thereby further reducing the number of staff available at any given time. The outcome of this was that the staff only had limited time to spend with the service users and in order to supervise them they encouraged the majority of the service users to remain seated in the main lounge. The pre-inspection questionnaire provided for the Commission of Social care Inspection indicated that staff were expected to provide two baths in the morning for service users and one in the afternoon. In other words the service users were provided, on average, with one bath a week. This issue of staffing was identified during the previous inspection. From observation of the staff it was apparent that they had established a close relationship with the service users. Several of the service users referred to the staff with genuine affection. Comments from the service users included, “ The staff are brilliant. If I didn’t like something then I would say so to the staff” and service users’ relatives stated, “ I’m really very happy – he’s (service user) getting better care than I could give”; “Fern Villa is absolutely brilliant – we looked at nineteen homes before deciding on Fern Villa” and “The staff do a fine job. Sometimes they are a bit short staffed”. A visiting medical professional said, “I think that the service users are well looked after and the staff are very caring. In the circumstances they cope quite well – I mean the limited numbers of staff can only do so much”. From discussions with and observation of the staff, it was evident that they had a good knowledge of the service users’ needs. They also demonstrated considerable empathy with the service users. A member of the care staff stated, “I enjoy working here. The residents are lovely. This is much better than the other place I worked”. The staff records indicated that since the previous inspection the staff had been provided with training in Adult Protection, medication procedures and health and safety. Training in food hygiene and first aid procedures had not been provided although according to the manager this training had been arranged. At the time of the inspection visit only three staff were current in first aid training and consequently it could not be guaranteed that there would always be a trained first aider available on each shift. Less than 50 of the care staff had achieved a National Vocational Qualification. All new staff had been provided with an induction training pack and had signed at the completion of each element of training. The records of two staff were examined. Whilst they confirmed that new staff were, in general, appropriately vetted, two of the more recently employed staff Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 21 did not have a contract of employment on their file and one only had one written reference. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is adequate. The registered manager is, to an extent, prevented from undertaking her specific managerial duties, such as the staff supervision, by being over involved in the direct provision of care and the lack of appropriate delegation of tasks to staff. The lack of health and safety documentation undermines the manager’s ability to ensure that the environment is safe. This judgement has been made using available evidence including a visit to this service. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has had a considerable number of years experience in managing the care home. The manager was still in the process of taking the Registered Manager’s Award. According to the manager, completion of this had been delayed due to poor standards of support provided by the college involved. The manager demonstrated a sound understanding of the service users’ needs and of those elements of care, such as the promotion of independence, that went to provide them with a good quality of life. The manager did not have access to e-mail or Internet facilities and consequently was not able to access the latest information on the Commission’s website. As previously identified in this report (See staffing) the main problem faced by the manager was the level of staffing. She stated, “I’ve had problems updating the paper-work because I spend most of my time doing hands-on care. I’ve managed to do some supervision for the staff but it’s about the lack of time. I don’t have a deputy manager so I spend a lot of time here. We don’t have a proper office and so the staff do hand-overs in the dining room – we still need to supervise the residents”. This limited level of staffing was also reflected in comments made by the service users, their relatives and a visiting healthcare professional. A basic quality assurance process was in place to enable the manager to assess the effectiveness of the service. This included regular meetings for the service users and the use of questionnaires. The manager had also audited each element of care on an ongoing basis. There was no specific evidence, however, that the findings of this quality monitoring process had been acted upon. The manager and the service users confirmed that the Registered Provider had made regular unannounced visits to the home that included an assessment of the service. These visits had also been made outside of normal working hours. There were, however, no reports provided for the manager to verify these visits. In general the premises were maintained to a good standard and it was apparent that the registered manager had taken appropriate action to ensure that they were safe. Basic risk assessments were in place. All accidents had been recorded. Records of fire safety were maintained in a standard notebook. Evidence was provided that the recommendations made by the Fire Officer had been addressed. The Environmental Health Department had inspected the home in September 2006 and the manager was in the process of addressing the related recommendations. The records confirmed that the call system had been regularly checked. The stair-lift, manual hoists and bath hoists had been serviced. There was not an Electrical Wiring Servicing Certificate available Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 24 although the manager provided evidence that the servicing of the system had been undertaken in November 2006. There was no evidence that the electrical equipment in the home, including that belonging to the service users, had been tested for safety (i.e. PAT Test). The hot water outlets were temperature controlled and the two outlets tested were within the required safety limits. According to the manager the Registered Person regularly checked the temperature of the hot water but these checks were not recorded and consequently could not be verified. It was the stated policy of the registered manager that staff did not become directly involved in the service users’ financial affairs or control their personal money. She said that the service users, or more usually their relatives, were encouraged to retain this responsibility. Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 25 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 2 3 2 2 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 2 2 Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 26 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. Standard OP2 Regulation 17(1)(2) Requirement Timescale for action 01/03/07 2. 3. OP19 OP27 23(o) 18 (1) 4. OP29 19 Copies of the contract and terms and conditions of residence provided for the service users must be available in the home. This must also include copies of any correspondence relating to a service user’s admission into the home including a record of the care home’s charges to each service user. The discarded/unwanted 01/03/07 furniture must be removed from the grounds of the care home. Additional staff must be recruited 01/03/07 to allow care staff more time to spend with service users on an individual basis and to free the manager to do her duties. (This requirement is outstanding from the previous inspection) Records for staff, which must be 01/03/07 kept in the home, must include all the information listed in schedules 2 and 4 of the Care Homes Regulations 2001. This must include copies of the staff’s Contract of Employment and verification that the vetting DS0000019669.V321575.R01.S.doc Version 5.2 Fern Villa Page 27 5. OP30 18 procedure has been fully undertaken such as copies of personal references and CRB checks. (This requirement is outstanding from the previous inspection). 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. They should also receive training in National Vocational qualification level 2 and in subjects relating to the ageing process. (This requirement is outstanding from the previous inspection). The registered manager must 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. (This requirement is outstanding from the previous inspection). A record of all unannounced statutory visits made to the care home by the Registered Person must be fully recorded and a report of the findings of the visit DS0000019669.V321575.R01.S.doc 01/04/07 6. OP31 9(2)18 01/03/07 6. OP37 26 01/03/07 Fern Villa Version 5.2 Page 28 7. OP38 13 provided for the Registered Manager. The registered provider must supply the Commission with the following safety certificates: PAT electrical equipment certificate and a current Electrical safety certificate. (This requirement is outstanding from the previous inspection). 01/03/07 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. Refer to Standard OP7 OP8 Good Practice Recommendations The service users’ care plans should accurately reflect any assessed change in that person’s need. A review of the bathing routines for service users should be undertaken to ensure that they receive a bath at a time and frequency of their choosing. A formal programme of nutritional screening for the service users should be developed. Advice on this programme should be obtained from an appropriate health care professional such as dietician. Facilities/equipment, such as sit-on scales, should also be made available so that staff can weigh those service users who are not weight bearing. The programme of social activities for the service users should be reviewed to ensure that it meets with individual’s needs and wishes. The planned menus should incorporate a degree of choice for the service users and they should be approached in advance of the meal in order to make that choice. Consideration should be given to replacing the existing call system with a more flexible system that enables the service users to use it from any point in their rooms without the need for inappropriate adaptations. DS0000019669.V321575.R01.S.doc Version 5.2 Page 29 3. 4. 5. OP12 OP15 OP22 Fern Villa 6. OP24 Consideration should be given to fitting the service users’ bedroom doors with appropriate locks and thereby enhance their privacy and dignity. Consideration should also be given to fitting the fire doors with automatic closers in order to make access to all parts of the care home easier for the service users. The Fire Department must, however, be consulted before any action is taken. The routine checks of the hot water outlets should be recorded so that the checks are verifiable. The registered manager’s job description should be reviewed to ensure that it is appropriate and that it enables her to fully undertake her management duties. It is also recommended that a deputy manager be appointed to act in the absence of the manager and thereby provide management continuity for the staff, service users and visitors to the home. Consideration should be given to providing the staff with appropriate facilities to enable them, for example, to discuss confidential matters without being overheard by the service users. This is particularly important during staff shift changes. All care staff should receive formal supervision at least six times a year. Ideally, this should lead to an annual appraisal. 7. 8. OP25 OP32 9. OP36 Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fern Villa DS0000019669.V321575.R01.S.doc Version 5.2 Page 31 - 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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