Inspection on 21/01/09 for Fern Villa

This inspection was carried out on 21st January 2009.

CSCI found this care home to be providing an Good service.

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 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 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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Fern Villa The Green Ellerker East Riding Of Yorks HU15 2DP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Janet Lamb     Date: 2 1 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Fern Villa The Green Ellerker East Riding Of Yorks HU15 2DP 01430422262 01482666013 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Rita McDonagh Type of registration: Number of places registered: Mr Jeremy William Southgate care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 23 The registered person may provide the following category of service only: Care Home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category, Code OP, maximum number of places 23 Dementia, Code DE, maximum number of places 23 Date of last inspection Brief description of the care home Fern Villa is a care home registered for 23 people over 65 years of age, of whom some 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 to the front. The first floor is served by a stair lift for less ambulant people. There are two lounges available and one dining Care Homes for Older People Page 4 of 32 Over 65 0 23 23 0 Brief description of the care home room and bathroom facilites meet the requirements of the standards in respect of numbers. There is a small sheltered garden to the rear of the house with patio furniture, though in the summer months people like to sit on the village green. There is car parking for approximately five cars. The home is privately owned. Weekly fees range from £360.00 to £450.00 per person per week. Extra may be charged if a double room is occupied as a single. Information about the service is made available to people via the statement of purpose, service user guide and inspection report, upon request. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The key inspection of Fern Villa took place over a period of time. It should have involved the sending of an Annual Quality Assurance Assessment (AQAA) document to the home several weeks before the site visit, but none was sent on this occasion. Surveys were issued to people living in the home and to the staff though at the end of December 2008. Information supplied in the surveys, taken from the random inspection carried out in July 2008, and taken from notifications and other information sent to the Commission was used to determine what it must be like living in the home. Then on 21st January 2009 Janet Lamb carried out a key inspection site visit to the Care Homes for Older People Page 6 of 32 home to interview people, the manager and staff, to observe interactions between people and between people and the staff and to view documentation and files relating to the service of care provided, in order to make a judgement on what the service of care is really like. Some of the premises was also inspected. What the care home does well: What has improved since the last inspection? Copies of peoples placing authority assessment, care plan and service level agreement are now available. Copies of the homes assessment of needs, care plans and contract of residency are also available. Peoples assessed needs are now being met more thoroughly. Daily life and social activities for most people are now improved and they appear to show more interest in life. The record of complaints now shows more information on how issues are resolved. Staff have undertaken safeguarding adults training. This should be updated annually. Some bedrooms and communal areas have been redecorated, extra furniture has been supplied in bedrooms, and fittings and linen such as curtains and bedding is being Care Homes for Older People Page 8 of 32 replaced. Staff are undertaking more mandatory training and have enrolled for NVQ qualifications. They are carrying out some cleaning responsibilities between them and a second cook is on trial with the view to permanent employment. The service has also slightly improved the kitchen facilities and introduced a much improved cleaning regime. Recruitment and selection policies and procedures are being followed more closely to ensure safe staff are employed. There has been some improvement in the promotion and protection of people and staff health, safety and welfare. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive appropriate contracts of care from the home and have the protection of a placing authority one. People also have their personal and health care needs appropriately assessed and recorded within the home, and staff skills are improving all the time so people are confident their needs are met. Evidence: Discussion with people in the home, the manager and staff and viewing of case files with permission from three people reveals there has been improvement in the way this set of standards is being met. People now have contracts of residence in place between the home and the placing local authorities in the area, titled Residential Service Notification. Of the three case files tracked two have such contracts, both signed and dated properly and in 2008. There are also contracts or terms and conditions of residence in place for people in the Care Homes for Older People Page 11 of 32 Evidence: home, between them and Quality Care UK Ltd, again signed and dated in 2008. Case files also contain copies of the placing authorities community care assessment documents. Two seen were dated February and November 2008. The home also carries out a short assessment of needs, which involves the taking of the persons picture, finding out their personal details, asking for a life history and carrying out a skills assessment and completing risk assessment documents. The skills assessment document covers such as mobility, dressing, eating and drinking, toilet use and continence, bathing, personal care, interest and motivation, awareness, memory recall, communication and orientation etc. There are twenty areas covered in the risk assessment some of which include falls, skin condition, vulnerability, smoking, catheter use, etc. to name a few. The assessment of needs then involves producing a list of areas that actually require an action plan to enable staff to meet peoples needs. Staff employed within the home are improving their skills as carers by undertaking training courses and NVQ qualifications and are better able to meet the identified needs of people in the home. Staff are learning about diversity and equality and about differences in peoples needs. There is still some way to go with staff skills. Trial visits and stays were not discussed and so this standard was not assessed, and intermediate care is not provided in the home so this standard is not applicable. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their personal and health care needs well recorded, monitored and satisfactorily met using the homes systems for recording and reviewing care plans. People are protected from the risk of harm from having the wrong medication because the staff are trained in medication administration and there are robust systems in place for the safe handling of medicines, based on a sound policy and procedure. They have their privacy and dignity upheld. Evidence: Discussion with people in the home, the manager and staff and viewing of documents with permission shows there are improvements in the home in the way the standards in this section are met People have fairly detailed care plans and accompanying risk assessment documents. These show staff how peoples needs are to be met and what support they need to maintain independence and good health. Care plans cover the twenty areas assessed under the homes risk assessment tool as well as those in the skills assessment Care Homes for Older People Page 13 of 32 Evidence: document. There is evidence to show people or their relative are included in the compiling of the care plan as people sign a document that says they have been include, understand the content of the care plan and acknowledge they can view it at any time. There are also copies of peoples placing authority community care care plan held in their file. Within the care plan there are pressure care and nutritional risk assessments completed as well as records of GP and district nurse visits, peoples weights, end of life requests, hospital discharge letters etc. and some people even have wheelchair contracts and toileting records, so health care needs are also included. Everyone has completed daily diary notes that show what care and support has been provided, as well as weekly key working notes and monthly evaluations. Care plan action plans are reviewed every three months and this is recorded next to each action area, while a full review of the care service is carried out every six months, every other one of which is attended by an officer of the placing authority and all other stakeholders. There is a medication administration policy and procedure in place that includes selfmedication, although no one self-medicates at the moment. Systems for handling medication are considered to be satisfactory now that two requirements made at the last key inspection have been met; to ensure there is a written protocol on administering as and when required medication, and to make sure staff administering drugs are properly trained and competence tested. Four staff responsible for giving out medicines are now trained according to the NCFE level 2 Handling of Medicines course and others have had in-house instruction with Boots Chemist in 2008. All of these staff have requested a more detailed medication administration training and are to undertake a Boots Chemist Advanced Medication Administration course in March 2009, along with the manager. Storage of medication is not as good as it could be but the manager has plans to relocate the storage of medication trolleys in another cupboard, once it has been made ready, and this will then be much improved. There are printed medication administration record (MAR) sheets in use that show when medicines were receipted into the home, who administered tablets, when and whether or not any were refused and returned. Boots Chemist carried out a full audit of the systems in June 2008 soon after a new contract was set up with them. People in the home are quite satisfied with the arrangements for handling medicines as none of them wish to have the responsibility for self-medicating for fear of forgetting or taking too many etc. Generally privacy and dignity is upheld - staff are discreet, care is given and health care professional visits etc. are carried out in private, people receive their mail unopened and they are addressed how they choose to be addressed. Care Homes for Older People Page 14 of 32 Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that are more able experience a good lifestyle of their choosing where possible. They enjoy a small variety of pastimes, receive visitors at their convenience, have some very good connections with the local community and enjoy satisfactory and nutritious food provision. Those less able could do to have a little more time invested in them to make sure they too lead satisfying and busy lives. Evidence: Discussion with people, the manager and staff and viewing of some documentation in case files with permission, reveals there has been more improvement in the opportunities for people to choose the way they lead their lives and make decisions. People have the opportunity to join in with pastimes held in-house, with planned outings to such as the pub or a restaurant, or to just keep their own company in their rooms. Some stay in their rooms and only ever come out for meals, others come and go as they please. Some, less able to make choices receive more assistance from staff and spend all of their waking time in the lounge or dining room. Pastimes enjoyed include dominoes, group crossword and sudoku, bingo, days gone by reminiscence, receiving visitors and conversing, watching DVDs, westerns mostly, listening and Care Homes for Older People Page 16 of 32 Evidence: singing along to music and especially visiting entertainers, and joining in with theme nights and birthday parties. People like to have a celebratory drink or a tipple just to cheer them up and all requests are carefully considered, but usually accommodated somehow, even if only with non or low alcohol drinks. Seasonal occasions are celebrated as well, and people recently enjoyed a Christmas party at a local works social club, a Christmas party for family and friends and one for people in the home only. There is a weekly activities plan on display in the entrance hall, though this is not always followed, and diary notes show what people have been involved in and where they have been etc. Outings are advertised in advance and people are encouraged to join in where possible. A little more could be done for those people less able and with cognitive impairment or sight and hearing loss, to encourage them to enjoy more satisfying pastimes. This is an area that tends to be more difficult in which to meet peoples needs. The local community is accessed through the churches in the area, and the schools that call to perform concerts or sing on the village green. The home usually hosts village green carol singers each year and provides refreshment after the event. A church service is held in the home each month and a visiting priest will provide holy communion on request. Visitors are frequent to the home and one spoken to says people are always made welcome. Generally those that are able make their own decisions on what to do, when, where etc. and do lead fairly busy lives within the home. There is only one person that completely handles their own finances, many others have family members or representatives that do so, and only one person has money held by the home. This is held at a sister home along with funds for two people living there. The general policy is that the company does not want the responsibility to handle money for anyone, but for three people it has no alternative. For these three people a company administrator holds computerised records of all transactions, issues regular statements and audits systems. Records were not viewed as part of this inspection as they are held at the sister home. If and when the person concerned needs money the manager arranges for it to be brought to the home. This person also has an officer of the East Riding of Yorkshire Council acting as appointee for them. Systems are considered satisfactory. Meal times were also discussed and people in the home say they get plenty to eat, it is good food and they can choose to have something different if they do not like it. Menus are roted every four weeks, include seasonal choices, though there is no written choice alternative to any of the three meals that are provided each day. People say they make requests in house meetings and can have something different if the food on offer is not what they like and there are several different foods provided each tea time. Lunch seen on the day of the site visit was minced beef, mashed potatoes, cauliflower, Care Homes for Older People Page 17 of 32 Evidence: carrots, green beans and gravy. Dessert was not seen. Where possible fresh meat and vegetables are purchased weekly when the manager takes a specific trip to the shops. This way she has control over the quality of food provided. There are no concerns regarding food provision. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good systems in place to enable them to be represented in any matter of concern or complaint and are satisfactorily protected from harm from abuse or neglect etc., so they know they will be listened to. Evidence: Discussion with people in the home, the manager and staff and viewing of records and documents reveals there are satisfactory systems in place to enable people to make representation and to protect them from harm. There is a complaint policy and a procedure in place for everyone to follow in the event someone wants to make a complaint. The procedure has time scales and clear information on who to speak with. There is also a complaint record available for logging complaints, how they were handled and their outcomes. People have mostly only made grumbles known, but these are also recorded. Information in the complaint record is more detailed and so the requirement made at the last inspection to make sure the record shows how complaints are handled, their outcomes and satisfaction of the complainant, has been met. Systems for handling complaints have improved slightly, but more importantly the service of care has improved so people grumble and complain less. The manager is approachable and understands that if things are not right she can only make them better if she is told, and so she welcomes complaints. There is one on-going complaint that has been investigated by East Riding of Yorkshire Care Homes for Older People Page 19 of 32 Evidence: Council Social Services department and has been considered not upheld, but the complainant is still dissatisfied, so it will take some time to resolve properly. There is a safeguarding adults policy and procedure in place, and records of any referrals made to the local safeguarding adults team would be kept, though this has not been necessary over the last twelve months. The home also has a Hull & East Riding of Yorkshire Council safeguarding adults procedure file available and staff have done some awareness training on a half day course with the consortium in October 2008. The manager has completed a full managers safeguarding training course some years ago and recently updated this on a refresher course, also in 2008. There have been no referrals to the safeguarding team in last twelve months. Staff show in interview they are aware of their safeguarding responsibilities. People in the home say they would speak up and talk to the manager if they were unhappy or felt they had been harmed in any way. There was a requirement at the last inspection to make sure everyone is trained in safeguarding awareness and knows how to report situations, and this has now been met. Care Homes for Older People Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are enjoying a house that meets their individual and collective needs for comfort and cleanliness. The general standards within the home have improved since the last inspection and staff are improving their skills and knowledge to maintain an infection free working and living environment. Evidence: Discussion with people in the home, the manager and staff and observation of some parts of the home reveals there has been considerable improvement in the decoration of rooms, the cleanliness of the premises and in the supplying of equipment. Many rooms have been repainted and emulsioned and some have extra items of furniture such as a second easy or dining chair. The bathrooms and toilets have been fitted with new toilet seats and one with a new fixed bath hoist. The main stairs has a new chair lift. An area still to be attended to is the rear garden paving stones that are still loose and therefore still unsafe for people to use. A second area still requiring attention is the upstairs bathroom, which still needs redecorating, some re-tiling and a new floor covering. New floor covering is still required in all bathrooms and toilets. The cook also works some hours as cleaner and handyman and has a planned maintenance and redecoration programme, which is gradually being worked through. Care Homes for Older People Page 21 of 32 Evidence: The location and layout of the home meets the individual and collective needs of people in the home to provide care and accommodation for older people. The manager informs us that the requirements made at the last environmental health inspection have now been met, with the exception of the kitchen floor covering. Requirements of the fire safety officer are now met after the provider arranged for an electrical safety maintenance check on the fire safety detection systems, before the expiry of a fourteen day immediate requirement notice, verbally given on the day of the site visit and followed up in writing shortly after. This had lapsed. A requirement made at the last inspection to fit security locks to bedroom doors to give people more privacy has not been completely met, though some people now have Yale locks fitted with the dead bolt removed, which is satisfactory and others have a small slide bolt fitted to the outside as a temporary measure. The home is now looking cleaner and smelling fresher, with the exception of one very bad malodorous bedroom and two malodorous bedrooms, which the manager and staff are well aware of. Use of a carpet cleaner is frequest. Eradication of malodours remains a recommendation of the report. Staff are soon to sign up to do an infection control course at Leeds College. Generally the laundry meets the Water Supply (Water Fittings) Regulations 1999, though a new floor covering could be fitted and some general tidying up and redecoration could be done. Old equipment needs to be disposed of quickly and properly. A new tumble dryer is urgently needed for staff to be able to do their jobs effectively. Care Homes for Older People Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have staff in sufficient numbers working in the home to meet their needs and there are also sufficient hours allocated to keeping the property clean. People have safe and satisfactorily trained, but not necessarily qualified staff caring for them. Evidence: Discussion with the manager and staff and viewing of staff files with permission reveals there has been some improvement in the systems for recruiting and selecting staff, in making sure they are trained and qualified and in making sure there are enough people on duty to meet peoples needs and to keep the home clean. Care staffing hours are still appropriate for meeting the needs of people in the home, as people say they are very well looked after, spend quality time with their key worker and usually get assistance when they ask for it. Rosters also show hours used on caring and generally there is sufficient to meet peoples needs. Some care hours and some hours allocated to a handyman each day have been used to ensure the home is cleaned and kept in a satisfactory condition and free from malodour. This shows in the home when visiting. There is one bedroom with very bad malodour and two with some malodour and these were discussed with the manager and staff. The number of staff with the required qualification does not yet meet the Care Homes for Older People Page 23 of 32 Evidence: recommended percentage of total care staff. Currently one staff has done NVQ in Care at level 3, and four have begun to do level 2. Efforts must continue to increase the number of staff with a recognised qualification in care. Recruitment and selection of staff has improved since the last inspection and three files seen show an application is completed, evidence of a persons identity is there in the form of copy documents for passport, driving licence, birth and marriage cert. There are also two written references for staff, except for one who came into the post straight from school, details of initial and full security checks with the Criminal Records Bureau, and supervision and training and development information. Recruitment and selection systems and practice has improved sufficiently to record a new rating of good for the standard. There is evidence in staff files of the training they have completed, but no information relating to having done an induction was seen. Training completed includes lifting and assisting people to move, basic medication administration, fire safety and safeguarding adults, and the cook has completed the basic food hygiene certificate. Courses still to be done are health and safety, infection control, planned for May 2009, and a more advanced medication administration course, planned for March 2009. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the benefit of an experienced and soon to be qualified and registered manager running the home. A satisfactory quality assurance system underpins the measuring of the services performance and peoples financial interests are safeguarded. People and staff have their health, safety and welfare satisfactorily promoted and protected. Evidence: Discussion with people in the home, the manager and the staff, and viewing of documents and records pertaining to quality assuring the service, handling peoples finances and safe working practices reveals there has also been improvement in this section. The manager has now been in post some sixteen months and though she has embarked on the NVQ level 4 Leadership and Management course and has completed the A1 Assessors course, the company has only recently submitted an application for Care Homes for Older People Page 25 of 32 Evidence: her to become the registered manager. This application is in progress. There is a quality assurance system in operation in the home and although it is still used tentatively it does involve some useful tools to check the effectiveness of the service. It involves audits of the service of care, meetings for people and staff that are minuted, staff training lists that are worked through, peoples care plan reviews, questionnaires sent to people and their relatives and health care professionals, monitoring of activities, menus, complaints and compliments, and monthly audits of the kitchen, food provided and the laundry service. The system has also been checked by the East Riding of Yorkshire Council in its assessment of the home for awarding part one of the quality development scheme. People spoken to say they are consulted about things that relate to them personally and that the manager and staff checks on them daily. There is a policy on handling finances, which states there will be no handling of money for people in the home. This is the case, but one new person to the home since the last inspection is in the situation where an officer of the placing local authority acts as an appointee and so their personal allowance entitlement has to be handled. This is done at Fern Villas sister home in the next village and requires the company administrator to hold funds for three people only in a non-profit bearing account for which three monthly statements are issued to their representative or family. The manager of Fern Villa requests money for the person concerned as they require it, though their cognitive ability is impaired and the manager is entrusted to make such decisions for them. All allowance credits and any expenditure is accounted for on a running computer balance, receipts are maintained and statements are issued. None of the systems were seen on this inspection. There are policies and procedures held for ensuring safe working practices within the home in respect of health, safety and maintenance. There are records of safety checks and maintenance certificates held for the areas included in standard 38. Some of these were sampled and included the fire safety, portable appliance testing, lifting equipment and stair lift, water storage, the oil fuelled boiler and the use of hazardous cleaning products. Weekly fire safety equipment checks are carried out and recorded on the emergency alarms, lights and detectors, and two monthly drills are held though people are only evacuated to an area. Staff attending a drill need to sign the record of the fire drill individually and not just have their name listed, as evidence of attendance. There is evidence that the fire extinguishers were last checked and a fire prevention officer visited to provide a fire safety instruction in October 2008. A fire safety officer also visited the home to check the electrical fire panel in February 2008. There was no Care Homes for Older People Page 26 of 32 Evidence: evidence of an annual fire safety check and certificate or of a portable appliance test though from an electrician and this was requested within 14 days of the inspection visit and was met before the compiling of this report. The fire risk assessment has been updated and the staff toilet in which the oil burning boiler is sited has been ventilated as requested at the last inspection. There has been no testing of the hot water storage tanks for legionella as requested, so this remains a recommendation of the standard and evidence of it being undertaken should be sent to the Commission within the next three months. There are no records of the stair lift and fixed bath hoist being serviced, but they are both new since September 2008 and so remain within their initial warranties, so maintenance certificates are not needed until the warranties expire. The company must make sure it meets the requirements of the Provision of Use of Work Equipment Regulations 1992 in this matter. The home has a Control of Substances Hazardous to Health file in which instructions for safe use of cleaning products are held for staff to consult so they use them safely. Generally the health, safety and welfare promotion and protection of people in the home and staff has improved, though there is still some tightening up to be done to make sure annual maintenance checks are done before they expire. Care Homes for Older People Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 9 13(2) The registered provider must 30/09/2008 make sure there is a suitable and secure place to store the new medication trolleys so that people are confident their medicines are stored securely and are not available to unauthorised persons. 2 19 23(2)(b) and (c) The registered provider must 30/10/2008 replace the carpets on the landing and in room 7. This is so people are confident they live in a safe, comfortable and homely environment. 3 19 23 The registered provider must 31/12/2008 refit and secure the paving slabs in the garden to ensure they do not pose a health and safety trip/fall hazard to people using the garden and grounds, so people know they will be safe when accessing the garden. The registered provider must 30/12/2008 make sure the toilets and bathrooms are kept in a good state of repair and decoration, and contain the Page 28 of 32 4 21 23(2) and 16(2)(c) Care Homes for Older People equipment required - the upper floor bathroom requires redecoration and a new floor covering, many toilets in the home require new floor coverings. This is so people are confident their environment is safe, clean and comfortable. Care Homes for Older People Page 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 4 The registered provider should continue to encourage staff to undertake qualifications and training, and to facilitate their completing it, so they improve their skills and competences to ensure peoples need are always met. The registered provider should offer more variety and appropriate pastimes to those people less cognitively able, so everyone in the home leads a fulfilling lifestyle and has their social and emotional needs met. The registered provider should replace the kitchen floor covering to meet the requirements of the environmental health officer, and so that the hygiene standards in the kitchen can be properly maintained. The registered provider should continue to fit suitable locks to bedroom doors for those able to use them, so that people have security for their possessions and belongings. The registered provider should make sure all bedrooms are free from malodour, so people have pleasant accommodation in which to live. The registered provider should encourage staff to undertake NVQs and seek to achieve at least 50 of care staff with the award, so people are confident qualified staff are caring for them. 2 12 3 19 4 24 5 26 6 28 Care Homes for Older People Page 30 of 32 7 30 The registered provider should make sure all new staff complete induction training and that it is recorded. Staff should also keep up to date with all annual mandatory training, especially in fire safety, assisting people to move, medication administration, infection control and safeguarding adults. The registered provider should make sure the hot water storage tank is tested for legionella bacteria and evidence should be sent to the Commission within three months of receiving this report, so people are confident they are protected frorm harm from disease. The registered provider should make sure staff sign the fire drill record to evidence they have attended the drill, so people are confident they are being protected from the risk of harm from fire. 8 38 9 38 Care Homes for Older People Page 31 of 32 Helpline: 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 We want people to be able to access this information. 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