Inspection on 22/01/08 for Fern Villa

This inspection was carried out on 22nd January 2008.

CSCI found this care home to be providing an Adequate 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 21/01/09

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Fern Villa The Green Ellerker East Riding Of Yorks HU15 2DP Lead Inspector Janet Lamb Key Unannounced Inspection 22nd January 2008 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.V358700.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.V358700.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 Lesley Ellis (Unregistered) 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.V358700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 08/08/07 Brief Description of the Service: Fern Villa is a care home registered for 23 people over 65 years of age, most of which have some level of 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 a parking area. The home is privately owned. Weekly fees range from £286 - £375 per person per week. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The key inspection of Fern Villa has taken place over a period of time and involved sending an ‘annual quality assurance assessment’ (AQAA) document to the home in early October 2007 requesting information about people and their family members, and the health care professionals that attend them, as well as asking for numerical data held in the home. We received the requested information on 12 December 2007 and survey questionnaires were then issued to a selected number of people and their relatives, their care manager, their GP and any other health care professional with an interest in their care. This information obtained from surveys, and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 22 and 23 January 2008 to test these suggestions, and to interview people, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. A total of two people, two staff, and the manager, were spoken to or interviewed during the site visit and one relative and two professional visitors were also spoken to. Several more people living in the home were observed. All of the information collected, in conversations, through observation and in survey questionnaires was collated to determine what it must be like living in the home. What the service does well: The service has a suitable contract of residence for people living in the home. It has an appropriate assessment process for assessing people’s needs and produces care plans that staff use to show how needs are met. It treats people with respect and upholds their right to privacy and dignity. The service has a satisfactory system of handling and storing medication. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 6 It promotes and encourages good contact between people, their family, friends and people in the community. The service encourages people to have control over their lives and to exercise choice wherever possible. It offers satisfactory food provision that meets people’s individual and collective needs. There is a competent manager that is soon to complete the required training course for her level of responsibility that runs the home in the best interests of the people living there. What has improved since the last inspection? What they could do better: The service could make sure all areas listed in 3.3 are covered in assessments and care plans and make sure action plans are clearer and more detailed. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 7 The service could make sure that, when people are prescribed medication on an as and when basis, a written protocol is in place advising staff under what circumstances it can be administered so that people are protected from harm. The service could make sure that all staff administering medication have received appropriate recognised and accredited training and are assessed as competent so that people in the home are protected from harm. The service could make sure people with impaired cognitive abilities are given the opportunity to undertake fulfilling pastimes and activities, so they are confident their lifestyle meets their expectations. The service could make sure the record of complaint shows how complaints are handled, what their outcomes are and whether or not complainants are satisfied, so that people are confident their complaints will be taken seriously and will be resolved satisfactorily. The service could make sure that people are protected from harm by the provision of training in how to deal with behaviour that is difficult to manage. Staff must also undertake safeguarding adults training with an external source where possible and on an annual basis, so that people in the home are protected from harm. The service could 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 service could make sure the toilets and bathrooms are kept in a good state of repair and decoration, and contain the equipment required – the upper floor bathrooms require redecoration and new floor coverings, many toilets in the home require new floor coverings and replacement toilet seats and covers, a small number of bedrooms require redecoration and the ground floor bathroom hoist seat should be replaced or cleaned and repaired. All of this is so people are confident their environment is safe, clean and comfortable. The service could make sure people’s bedroom doors are fitted with appropriate locks so their privacy and dignity is enhanced. Where this is not possible, due to the complex needs of people, a risk assessment must be undertaken and a copy held on file. The service could provide domestic staff to ensure that the home is maintained in a clean and hygienic state and would enable care staff to spend more time with people. The service could make sure that records for staff include all the information listed in schedules 2 and 4 of the Care Homes Regulations 2001. CRB checks must be done and received before staff begin working in the home, so that people are protected. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 8 The service could make sure all staff receive mandatory training to assist them to carry out their duties safely. They should also receive training in National Vocational Qualification level 2 and in subjects relating to the ageing process, so that people are confident skilled and safe staff are caring for them. The service could make sure the appointed manager submits an application to become the registered manager, so people know the home is run by a person ‘fit,’ experienced and competent to do so. The service could make sure the quality assurance systems are fully operational, consult all stakeholders, and are reviewed in line with the requirements of regulation 24, so people are confident the home is run in their best interests. The service could make sure the home is safe by obtaining certificates of safety for all of the equipment used, maintenance carried out and services accessed as listed in standard 38. All of this is so people are free from the risk of harm. The service could take adequate precautions against the risk of fire and make sure the fire risk assessment document is up-to-date and relevant. Also that the weekly check on the safety systems and equipment are properly recorded in a timely fashion. Also that fire safety drills carried out are properly recorded in a timely fashion, so people are protected from the risk of harm from fire. 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.V358700.R01.S.doc Version 5.2 Page 9 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.V358700.R01.S.doc Version 5.2 Page 10 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): Standards 2, 3 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People’s individual and diverse needs are assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. Most of them have contracts of residence now. EVIDENCE: Discussion with people, the manager and staff and viewing of files with permission reveal there are now more comprehensive systems for assessing people and providing them with information and a contract of residence. The manager now has a good system for assessing people before they move into the home, and documents completed by any placing local authority are Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 11 also obtained as a basis on which to build a plan of care. Both of these are also now held on file in the home. The home now carries out a ‘short assessment’ prior to the full skills assessment and the latter contains 12 areas for checking need. These range from mobility to continence, to interests, to communication etc. The documents seen did not have a date of completion on them and this is recommended at the end of the report. The short assessment form shows name, address, religion, medication taken any loss of senses, allergies etc. and tells people in written format that their needs can or cannot be met in the home. There are now contracts of residence in place, but not for everyone and there are up-dated ‘statements of purpose’ and ‘service user guides’ available. The contracts need to be established for everyone, as it seems only newly admitted people have one at the moment. Of the people spoken to one was not aware of the assessment process or that documents were held in the home relating to his needs, but he was happy for them to be viewed. Another person was aware and remembered the assessment being done. She was also happy for documents to be viewed. She said, “I am very happy and grateful to be here in the interim, and anything that will help me to move on to where I want to be is alright with me. I did move here straight from hospital, so much of the work was done for me.” The manager has only been in post for approximately four months, but already she has made vast improvements in the monitoring, assessing and recording systems in use. Standards two and three are now met. Standard six is not applicable. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9 and 10. People who use the service receive adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their health and social care needs fairly well documented in care plans, so they are confident their identified needs will be met. No one takes the opportunity to self-medicate, but people’s medication needs are well managed. People enjoy good levels of privacy and staff adequately maintains their dignity. People are confident their overall quality of life is improving. EVIDENCE: Discussion with people, staff, the manager, a relative and two visiting health care professionals and viewing of documents and files reveals there are now much improved systems and records for assisting people with their personal care and health care needs, with encouraging people to self-medicate and administering medications and with upholding privacy and dignity for everyone. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 13 There are now improved plans of care in place that cover 19 areas of living and care support that also have plans of action for staff to follow to meet the assessed needs. These care plans are quite effective but need to include all of the areas listed in standard 3.3 and need developing to show more detail in the action plan, such as preferred bath days/times, medication taken and when, and mobility equipment used and how used etc. Those areas that are missing are falls and communication. These should be fully included in care plans and have action plans devised to meet needs. The care plans in place are completely new since October 2007 and are documents that staff now follow and use. A visiting relative commented that health care has improved for people and that even though her mother often discards her hearing aid staff always manage to keep it safe for the next time she needs to use it. Her mother has also increased in weight, which was necessary for her health, and she is more alert and talkative. The home has jointly purchased a sit-on weighing scale with its ‘sister’ home, which is transferred back and forth each month, so that everyone is given the opportunity to be weighed as part of maintaining good checks on their health. This was a requirement of the last inspection. There is a policy and procedure for administering medicines in the home and there is a monitored dosage system in use that is provided by the local dispensing GP surgery. Medicines are kept in a safe storage place and there is an appropriate fridge for those requiring colder storage. No one selfmedicates at the moment. The manager is considering changing dispensing arrangements from another supplier, as a free fax machine and medicine trolley would be provided, as well as the chance to access six-monthly medication handling and administering training. Medication administration record sheets are available and used appropriately and those seen for identified people are satisfactorily maintained. Practice observed in administering medicines is also satisfactory. Staff confirm in interview they have completed medication administration training, and records in their files show dates when the training was done. Most completed training in a previous job however, but the manager has re-assessed their competence to handle medicines since October 2007. Those staff whose training is more than a year old are recommended to refresh the training annually. All people in the home have had their medications reviewed on the request of the manager since October 2007, and should only be taking what is absolutely necessary now. One person interviewed said, “I have tablets to take every month and the care home looks after them. I am happy with that.” Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 14 The manager explains that almost all of the staff are newly recruited since October 2007, and therefore all of the mandatory training is being set up and completed whenever possible. People are observed to receive assistance and support in a dignified manner and personal care is usually given in private. Care staff uphold this view where possible. One person requiring more assistance than most was observed being helped to table for lunch by two staff and a third provided emotional support. Two visiting professionals, one from health and one from social services, were briefly interviewed and stated that the care and health support to people in the home has improved greatly since the new manager had been in post. They visit one person on a weekly basis at the moment to offer support and have noticed a very marked improvement in that person’s health, physical appearance and general wellbeing. They have also noticed a marked improvement in the demeanour of other people in the home and in the general environment, people being much more settled and calmer going about their daily routines and the home being cleaner and fresher. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both before and during the visit to the service. People have improved opportunity to join in with daily planned activities, enjoy good contact with relatives and friends, have good opportunities to be selfdetermining, and enjoy satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Discussion with people, a relative, staff and the manager, observing of interaction between people, between people and staff and people and their relatives, and viewing of plans, records and files reveals people lead fairly quiet lives. Some have opportunities to engage in activities and receive plenty of visitors, and all exercise some control over their lives and enjoy satisfactory food provision. There is a basic activity plan for all people to join in with, although there is no individual plan for anyone not wishing to. One person interviewed said, Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 16 “There isn’t much done here. I used to play dominoes. I used to play cricket, but can’t now. I played until I was 70. I used to do a lot of cycling, to work as well as for fun. You know I’ve written a book on farming.” People were observed playing dominoes, watching television in their rooms or the lounge, and listening to music. Discussion with the manager reveals sometimes people go to the pub with male staff, and at least two people go out with the manager to do small ‘bits’ of shopping etc. Some people had different interaction with staff, such as brief conversations, sharing of a joke etc., but not for any length of time, except one person that spent five minutes talking to her favourite staff member and exchanging kisses with her. Only a sample of the day’s interaction was observed, but generally people are relaxed, exchange verbal banter and smile. Those that are less able, physically and mentally, are not satisfactorily stimulated though. More needs to be done to enable them to lead more fulfilling lives. One relative that provided an interview said the home’s activities had improved of late and although her mother has visual impairment she now has access to a large screen television, which has made a difference to her. She also mentions that the home facilitated a private family Christmas lunch in the quiet lounge for her mother, which was very successful and enabled her mother to enjoy having several generations of her family around her, but still access carer support and care when needed. There is a monthly religious service in the home of Christian denomination, but no other type of service, as none of the people in the home at the moment have differing needs. There are no restrictions on receiving visitors to the home, and anyone wishing to go out is assisted, but relatives are encouraged to do this. There are opportunities to go to the pub with male staff or to the shops with the manager. The manager intends to improve contact with the local community and make more use of the village green as the weather improves. Contact with local schools and groups has already improved, in that concerts were held in December with school children and one of the churches. There are set menus on offer with a choice alternative if the meal is not wanted. The new chef, with Intermediate Food Hygiene certificate, said he has adequate resources and budget to provide a nutritious meal and that equipment repairs requested at the last inspection have been completed. The fridge handle has been repaired. There is now a formal process for nutritionally screening new people to the home, which also involves taking of advice from the dietician. The kitchen is now looking very ‘tired’ and worn and as a medium-term plan could do to be refurbished. This is recommended in the section on the environment. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 17 People spoken to are relatively satisfied with food provision, are given little chance to have input into menu compilation, but do say the meals are good. One person spoken to would have preferred the main meal of the day in the evening as she is used to, but recognises she has to fit in with everyone else. She only plans to recoup in the home for a short while anyway. Other people have no issues with the food or meal times. One said, “The food is very good, I’ve not one complaint.” Lunch seen on the second day of the site visit was shepherd’s pie, Savoy cabbage, peas, and sweet corn, followed by rhubarb crumble and custard. The home has traditionally provided fish and chips from a local chip shop each Friday and still does so. There are no adverse comments from people, relatives or other stakeholders about any of these areas. Observation of support given showed people are treated kindly and given chances to make decisions, within their capabilities. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 18 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): Standards 16 and 18. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People make use of informal complaint processes and systems and have all issues dealt with appropriately, so they are confident their concerns are dealt with effectively and efficiently. They also experience adequate promotion and protection of their welfare and so feel satisfied the systems in place to protect them are improving. EVIDENCE: Discussion with people living in the home, the manager and staff, and information taken from surveys and seen in records reveals people and their relatives know how to make a complaint and to represent themselves, and staff are well aware of their responsibilities to protect people and to report any actual or suspected incidents of abuse. There is a policy and procedure for making a complaint or for dealing with suspected or actual abuse. Staff have received information in handling complaints and in handling information of a safeguarding nature, but they have not had recent external training in how to deal with and report or record safeguarding issues. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 19 There have been two complaints to the home in the last twelve months, one passed through us. One was satisfactorily resolved and one is still awaiting an outcome. Records are held to show what complaints are made, but it needs to detail how complaints are handled and what action has been taken to resolve the issues. In interview staff say they have not had safeguarding training with their current employer, but have covered issues in their induction packs and they show that they have a basic understanding of their responsibilities. It is required that all staff complete up-to-date safeguarding adults training with a recognised source as soon as possible. A mandatory training programme has been devised and the manager is aware of the safeguarding training available from the East Riding of Yorkshire Council. This is being accessed for staff in February and March 2008. There have been no safeguarding referrals made in the home in the last twelve months. People spoken to say they feel well looked after and only have to ask one of the staff if they have any concerns. A relative feels the home has improved and that people are much more settled and relaxed. “I used to hear lots of shouting, but now people are much calmer.” She sees different staff throughout the day and evening and feels levels have improved. Her mother now speaks with her more and with the staff. The relative knows how to complain and has approached the manager about issues and these have been resolved satisfactorily. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 20 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 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have a satisfactorily maintained environment in which to live, that is safe, clean and comfortable, so they are fairly confident they have adequate standards of accommodation. EVIDENCE: Discussion with people and the manager and viewing of a selection of rooms and the communal areas of the home reveal the property is suitable for its stated purpose of providing care and accommodation to older people and the house is adequately maintained, clean and comfortable. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 21 The requirements and recommendations made at the last inspection were discussed and checked, to find that call bells have been extended and furniture lay out has changed to ensure people have better access to the call system. Also that old furniture has been removed from the grounds, that hot water outlets at basins are being checked and recorded monthly, and at baths are being checked and recorded daily. Documents were seen. Two requirements have not been met yet and will remain as requirements. Bedroom doors have not been fitted with locks for securing peoples’ belongings, and loose paving stones to the rear of the house have not yet been replaced or remounted. The manager discussed proposed plans to seek several quotes from locksmiths for the fitting of suitable locks to bedroom doors. Also to either fence off the area of unstable paving stones or to concrete part of the area to enable people to have safe access in the warmer months. Work must be completed to meet these outstanding requirements before the next inspection activity. There are suitable mobility aids and adaptations in toilets and bathrooms and in some people’s bedrooms. Bedrooms are suitably furnished and decorated, with only one or two rooms looking ‘tired’ and in need of new paint and paper. The bathrooms on the upper floor of the old house have not been used for some time with the exception of use of the toilets, and are now in need of refurbishment. One bathroom needs a new floor covering and the other needs redecorating. The main and more widely used bathroom on the ground floor is in a better condition. There is a fixed bath hoist the seat of which, however, requires replacing as it is peeling badly underneath. The fourth bathroom, which is also on the ground floor, is used as the hairdressing room. Some of the toilet seats in the home remain old wooden ones and should be replaced with more hygienic and easily cleaned plastic ones. The kitchen is now looking ’tired’ and should be considered for refurbishment in the medium-term. The laundry room is also looking ‘tired’ and requires remedial work to the walls and floor surface. This could be done as an interim measure and a full refurbishment could be done as part of a longer-term plan. It remains that both the kitchen and the laundry are due for refurbishment and upgrading. The house is clean and comfortable and people have no adverse comments to make about the environment or their personal space. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People are cared for by a caring group of staff that are only adequately recruited, and that have minimal training, though this is improving. Staff are confident in their roles and are deployed in satisfactory numbers to meet people’s needs, so people enjoy an adequate service of care. EVIDENCE: Discussion with the manager and staff, viewing of rosters and using information from the home reveals there has been improvements in this area of staffing. The Residential Staffing Forum figures and the planned rosters show the home is sufficiently staffed in terms of staffing hours provided per week. Forum figures require 289.82 hours for 5 high, 5 medium and 4 low dependency people. According to the roster for a two-week period the home currently provides an average of 336 care hours per week. There is a vacancy for an extra 5 hours a day, 35 per week, which is not yet filled due to there being low numbers living in the home. This will be used as and when numbers increase. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 23 There is a full time manager in the home each weekday, that works hands-on where necessary, but still no domestic or housekeeper. At the moment the staffing figures are sufficient to meet the needs of people living in the home, but a cleaner is still required to ensure care staff only spend time caring for people and supporting them more thoroughly, and not doing cleaning tasks. The manager is considering taking on a domestic three days a week initially and has advertised the position. Standard 27 is met, but not entirely, as 27.7 still needs to be met. Of the nine care staff employed only four have achieved NVQ level 2, but two of these are now doing level 3 and there are another two staff undertaking their Skills For Care ‘apprenticeship,’ which is the induction course prior to NVQ, but is not the NVQ proper. This gives the home 44 of care staff with the required qualifications. Efforts need to continue to ensure the 50 target is achieved. It is acknowledged that staff are a new group of workers to the home since October 2007. There is a recruitment and selection policy and procedure in place, but practice has not been good. Staff files viewed with their permission show evidence of identification, criminal records bureau checks, references undertaken, and all of the homes recruitment documentation. However, of the three files seen all three showed staff began working in the home before their CRB proper was received. The manager assured us that POVA first checks had been done though. This practice should cease and staff should only begin working once their check has been completed and received. Also one staff did not have copies of references, and these were still being chased up. Systems are not as robust as they should be and do not properly protect people living in the home. Opportunities for training have improved since the new manager came to post. Staff have signed up for and started NVQs, they have all begun to complete the East Riding of Yorkshire Council induction pack, and they have completed dementia awareness and had their competence to administer medications checked. The manager explains that all staff are to undertake all of the mandatory courses over the next few months. A training programme is being devised and where possible training is being sought externally. This is an area that still needs to be achieved, and the manager must concentrate on making sure all staff do safeguarding adults training, an accredited medication administration course, and fire safety awareness and evacuation drills, as well as moving and handling techniques and use of hoists, health and safety and first aid. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People live in a home that satisfactorily run and in their best interests, and where adequate systems are in place to determine the quality of the service, but need improving and developing. People’s financial interests may be safeguarded, though their health, safety and welfare are not always promoted and protected, so they are not always confident they will be safe and well cared for. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 25 EVIDENCE: Discussion with people and the manager and viewing of documents and records reveal people and the staff benefit from a satisfactorily run home that is improving each day. Standard 31 requires there to be a competent and qualified registered manager in post. The current manager has only been in post for three months and is gradually making effective changes in how the home is run. She is currently undertaking NVQ Level 4 Registered Manager’s Award, has done safeguarding adults training for managers and has several years experience in the caring profession. She needs to submit an application to become the registered manager by the end of April 2008. Standard 33 on quality assurance systems was not assessed and only briefly discussed. There are stakeholder surveys available to send out to determine views of the service and the East Riding of Yorkshire Council quality development scheme is being looked at, but at the moment systems are not fully operational. The standard is not met. In respect of standard 35, information from the AQAA and from the manager is that people in the home do not have their financial affairs dealt with by anyone working in or owning the business. Relatives usually have control over finances where people are unable to do so themselves. No checks were made to determine the meeting of this standard. Requirements made under standard 38 at the last inspection were discussed with the manager and information was checked in documents. Arjo Mecanaids last carried out bath hoist, lifting hoist and stair lift maintenance on 24/06/06 according to the documents available and so up to date maintenance is still required. There is no passenger lift. M Hathways of Kingswood carried out a full electrical safety wiring check on 29/08/07, but there was still no evidence of a portable appliance test on electrical equipment used in the home. The home has a fire safety detection system in place that is checked for correct functioning each week and recorded in a fire safety record. Although the record was being maintained there were no details for January 2008. Recording of weekly checks must be maintained. There is a fire risk assessment document in place, but it is dated May 2006 and therefore needs urgent reviewing. The last Humberside Fire and Rescue Service visit was done on 15/09/06, probably as a follow up visit to the one done on 24/04/06 as noted at the last key inspection. There is no record of staff fire safety drills being carried out though the manager informs us drills are part of the weekly Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 26 check. An improved record sheet is needed to show equipment checks and fire drills carried out. Dates, times, people involved, nature of the check or duration of the drill etc. must be recorded. Fire extinguishers are noted as having last been serviced on 15/01/08. There is still no legionella test certificate for the water storage system. The manager believes this test has not been carried out recently and will arrange for one to be done. Environmental Health Officer issues raised at the last inspection they undertook have now been dealt with: new kitchen units fitted, broken hob rings replaced, freezer handle repaired, fridge temperatures now being taken and recorded, food being probed and recorded, and a list of foods consumed is now being maintained. People in the home that use a wheelchair are being reassessed for the equipment they have and changes will be made if deemed necessary. This is still ongoing. The only other area considered in respect of spot checks on health and safety of people and staff is the maintaining of Control of Substances Hazardous to Health information held and practices carried out. There is a COSHH file and staff have instructions on how to dilute and use products safely. The manager confirms she will endeavour to deal with all of these shortfalls that are not of her initial making; she has inherited issues that have not been addressed. Therefore she is advised to read the information at standard 38 and to ensure all areas of health, safety and welfare of people and staff are appropriately promoted and protected. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 27 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 28 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 OP29 Regulation 19 Requirement Timescale for action 30/04/08 2 OP30 OP28 18 The registered provider must make sure that records for staff include all the information listed in schedules 2 and 4 of the Care Homes Regulations 2001 - copies of the staff’s Contract of Employment and copies of personal references. CRB checks must be done and received before staff begin working in the home. CRB’s had been done but dates show that staff actually began working before these were received. All of this must be done in timely fashion so that people are protected from harm. (This requirement, in a changed form, is still outstanding.) The registered provider must 30/06/08 ensure that all staff receive mandatory training to assist them to carry out their duties safely including the following topics: Assisting people to move, use of hoists and equipment Basic food hygiene First Aid Health and safety DS0000019669.V358700.R01.S.doc Version 5.2 Fern Villa Page 29 Infection control Fire safety Medication administration Safeguarding adults They should also receive training in National Vocational Qualification level 2 and in subjects relating to the ageing process, so that people are confident they are cared for by skilled and safe staff. (This requirement, in a changed form, is still outstanding.) The registered person must ensure that the home is safe by obtaining certificates of safety for the following: Portable Appliance Testing Emergency call system Bath and lifting hoists Evidence that the water is free from the legionella bacteria. Oil Heating system. All of this is so people are free from the risk of harm. (This requirement, in a changed form, is still outstanding.) The registered person must ensure that when residents are prescribed medication on a as and when basis that a written protocol is in place advising staff under what circumstances it can be administered so that people in the home are protected from harm. (This requirement is still outstanding from the last inspection.) The registered provider must ensure that all staff administering medication have DS0000019669.V358700.R01.S.doc 3 OP38 13(4) and 23(5) 30/06/08 4 OP9 13(2) 30/04/08 5 OP9 13(2) and 18(1)(c) 31/05/08 Fern Villa Version 5.2 Page 30 6 OP18 13 (6) 7 OP19 23 8 OP24 23 9 OP27 18 received appropriate recognised and accredited training and are assessed as competent so that people in the home are protected from harm. (This requirement is still outstanding from the last inspection.) The registered provider must ensure that people are protected from harm by the provision of training in how to deal with behaviour that is difficult to manage. Staff must also undertake safeguarding adults training with an external source where possible and on an annual basis, so that people in the home are protected from harm. (This requirement, in a changed form, is still outstanding.) The registered provider must 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. (This requirement is still outstanding from the last inspection.) The registered provider must ensure that people’s bedroom doors are fitted with appropriate locks so their privacy and dignity is enhanced.’ Where this is not possible due to the complex needs of people a risk assessment must be undertaken and a copy held on file. (This requirement is still outstanding from the last inspection.) The registered provider must provide domestic staff to ensure that the home is maintained in a DS0000019669.V358700.R01.S.doc 30/06/08 31/07/08 30/06/08 30/06/08 Fern Villa Version 5.2 Page 31 10 OP7 15 11 OP12 12 12 OP16 22 13 OP21 23(2) and 16(2)(c) clean and hygienic state and free from dirt and unpleasant odours. (This requirement is still outstanding from the last inspection.) The registered provider must make sure care and health care plans meet standard 7.2 and contain all of the information required in standard 3.3, so people know their care and health care needs are being met. The registered provider must make sure people with impaired cognitive abilities are given the opportunity to undertake fulfilling pastimes and activities, so they are confident their lifestyle meets their expectations. The registered provider must make sure the record of complaint shows how complaints are handled, what their outcomes are and whether or not complainants are satisfied, so that people are confident their complaints will be taken seriously and will be resolved satisfactorily. The registered provider must make sure the toilets and bathrooms are kept in a good state of repair and decoration, and contain the equipment required – the upper floor bathrooms require redecoration and new floor coverings, many toilets in the home require new floor coverings and replacement toilet seats and covers, a small number of bedrooms require redecoration and the ground floor bathroom hoist seat should be replaced or cleaned and repaired. All of this is so people are confident their environment is safe, clean and comfortable. DS0000019669.V358700.R01.S.doc 31/05/08 31/05/08 31/05/08 31/07/08 Fern Villa Version 5.2 Page 32 14 OP31 8 and 9 15 OP33 24 16 OP38 13(4) and 23(4) The registered provider must make sure the appointed manager submits an application to become the registered manager, so people know the home is run by a person ‘fit,’ experienced and competent to do so. The registered provider must make sure the quality assurance systems are fully operational, consult all stakeholders, and are reviewed in line with the requirements of regulation 24, so people are confident the home is run in their best interests. The registered provider must take adequate precautions against the risk of fire and make sure the fire risk assessment document is up-to-date (must be reviewed) and is relevant. Also that the weekly check on the safety systems and equipment are properly recorded in a timely fashion. Also that fire safety drills carried out are properly recorded in a timely fashion, so people are protected from the risk of harm from fire. 30/04/08 30/06/08 31/05/08 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 Refer to Standard OP2 Good Practice Recommendations The registered provider should make sure all people living in the home have a contract of residency or a statement of terms and conditions of residence, so they know their interest are safeguarded. The registered provider and manager should make sure all DS0000019669.V358700.R01.S.doc Version 5.2 Page 33 2 Fern Villa OP3 3 OP8 documents used in the home are dated and signed by people or their representatives, so they know their care is being regularly monitored, and that they are confident they are being included in decisions. The registered provider should make sure all people in the home have their health care needs reviewed and action plans in care plans changed to reflect this, so they know their health needs are being met. Fern Villa DS0000019669.V358700.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V358700.R01.S.doc Version 5.2 Page 35 - 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. 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