Inspection on 06/03/06 for Fernbank

This inspection was carried out on 6th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fernbank 10/10/06

Fernbank 28/11/05

Fernbank 10/01/05

Fernbank 10/08/04

Similar services:

Chirnside House

Sunny Bank (P.R.S.) Ltd

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Fernbank 93 Queens Road Oldham Lancashire OL8 2BA Lead Inspector Steve Chick Unannounced Inspection 6th March 2006 12:30 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 Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 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. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fernbank Address 93 Queens Road Oldham Lancashire OL8 2BA 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) 01616264079 0161 626 4079 Mr Mark Brakspear Mrs Margaret Lorraine Brakspear Mrs Lynda Bennett Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (13) Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user up to 13 OP, up to 10 MD and up to 10 MD(E). Date of last inspection 28th November 2005 Brief Description of the Service: Fernbank is a detached Victorian property, registered to provide care for up to 23 people suffering from mental health problems and for people with disabilities resulting from Old Age. Their aim is to provide community based living with integration into the wider community, where possible, for those service users with mental health problems. Facilities include seven single bedrooms and eight double bedrooms. Several bedrooms have en-suite toilets. There are four lounges, one of which is the home’s smoking area, and one dining room. There was a well maintained garden to the front of the building and a smaller, secluded, patio garden area to the rear. The home is a privately run business owned by Mr and Mrs Brakspear. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection discussion took place with five service users and one member of staff was interviewed in private. Additionally discussions took place with the manager and one of the owners. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, including medication records maintenance records and the complaints log. This inspection was unannounced and not all standards were assessed. It is strongly recommended that this report is read in conjunction with the report of the previous inspection which took place in November 2005. All service users spoken to during the inspection were positive about their experiences in the home. What the service does well: What has improved since the last inspection? Staff recruitment is undertaken with more rigour. Several areas of administration had improved, offering more transparency of the service offered. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Each service user is appropriately assessed before moving to the home to ensure the home can meet their assessed needs. Service users are given a copy of the home’s terms and conditions to ensure they are aware of their rights and responsibilities while at fern Bank. EVIDENCE: A random selection of service users’ files was scrutinised. All had a copy of the home’s terms and conditions. Subject to the capacity of the service user these had also been signed and dated to indicate their acceptance. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 9 There was documentary evidence of an appropriate assessment having been undertaken prior to each service user moving to Fern Bank. The manager reported that any assessment undertaken by a third party was complemented by the owner undertaking his own assessment to ensure that the home was suitable to meet the needs of the service user. Fern bank does not offer Intermediate Care. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Written care plans were regularly reviewed to ensure they continually reflected the care needs of the service user. Service users health needs were appropriately met through access to medical professionals in the community. Medication procedures were not rigorously followed, which may put service users’ health at risk. EVIDENCE: A random selection of service users’ files were scrutinised. All had a written plan of care and a good ‘social history’ which would further enhance the home’s ability to meet their needs in an individualised way. There was documentary evidence, by way of the service user’s signature that they had been involved in the care planning process. In one example the service user had not signed as they did not have the capacity to fully Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 11 understand the written plan. The manager reported that the contents of the plan were none the less shared with her. There was documentary evidence of the care plans being regularly reviewed. It was also reported by the manager that more structured reviews, involving the service user and representatives was planned for later in the month. Copies of correspondence inviting relatives to these reviews was seen. Daily records which were seen included appropriate observations following a request for monitoring when a service user reported being in discomfort. Records and discussion with service users confirmed that people had appropriate access to the full range of medical and para medical services available in the community. It was reported by the manager that GPs had been asked to review the medication for all service users and one GP (responsible for 50 of the service users) was due to visit the home to undertake this for their patients, later in the month. Fern Bank had an appropriate medication policy and procedure which was not scrutinised at this inspection. The home used a pre dispensed monitored dosage system to administer service users’ medication. Medication was seen to be stored appropriately. Medication administration records presented as being predominantly appropriately completed. However one example was seen which served to undermine the credibility of the records. This was in connection with a medicine which was recorded as having been given, but had not been. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this inspection. EVIDENCE: Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Fern Bank’s complaints procedure is implemented to address service users’ complaints appropriately. EVIDENCE: The home had an appropriate complaints procedure which was not scrutinised at this inspection. Inspection of the record of complaints indicated that one complaint had been received by the home since the last inspection. Discussion with the manager indicated that, whilst any issues are taken seriously and addressed in a timely manner, only formal or more serious complaints were routinely recorded. All service users and staff who were asked expressed the view that any complaint would be dealt with appropriately by the staff and management at Fern Bank. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. Fern Bank offers a well maintained, safe, clean, tidy and odour free environment for service users. This includes both the communal areas and service users’ own bedrooms which they can personalise. Appropriate communal areas exist to accommodate the needs of smokers and non smokers. Appropriate toilets and bathrooms were available for all service users to maintain their dignity. EVIDENCE: Fern Bank presented as being appropriately maintained and decorated throughout. A tour of the building was undertaken and no issues requiring remedial action in connection with maintenance of the décor, fabric or furniture, were identified. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 15 A selection of bedrooms was seen. These presented as clean, tidy and appropriately personalised. Several bedrooms are double rooms. Service users who were asked, expressed satisfaction with the accommodation. The home has three lounges and a dining room. One lounge is the dedicated smoking area. Fern Bank has well maintained gardens to the front and rear. Appropriate toilet and bathing facilities were available. The home presented as clean and tidy throughout, with no unpleasant odours. This was confirmed as the usual state of the building by staff and service users who were asked. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29. Staff are appropriately vetted and have access to training opportunities to protect the interests of the service users. EVIDENCE: The manager reported that seven of the 17 care staff held an NVQ II. This represents 41 of the care team. A selection of certificates were seen to verify this information. The manager also reported that two more staff were undertaking NVQ II and one was registered on the course but had not yet started. Assuming these staff are successful on the training, 59 of the staff team will be appropriately professionally qualified. The member of staff who was interviewed said she was looking forward to undertaking the NVQ and that the owners and manager were supportive of staff undertaking training. The manager reported that only one member of staff had been recruited since the previous inspection. Scrutiny of their employment file confirmed that they had been appropriately vetted before commencing work at Fern Bank. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38. Service users views are taken into account in the running of the home. Internal procedures offer appropriate protection for service users’ personal finances. Appropriate procedures are followed to maintain the health and safety of service users and staff. EVIDENCE: The home runs a weekly meeting to which all service users are encouraged to attend and express their views. It was reported that Quality Audit and Quality Monitoring questionnaires had been sent out shortly before this unannounced inspection. Although not all had Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 18 been returned and consequently they had not been fully assessed, the manager reported that those returned so far were positive. There had been some delay in sending out the annual questionnaires which had resulted in it being over twelve months since an annual development plan, based on the findings, had been produced. A selection of records relating to money held by Fern Bank on behalf of service users was scrutinised. These presented as being appropriately maintained, with receipts being obtained for purchases made on behalf of service users. Appropriate maintenance records relating to equipment in the home, including fire detection and alarm and the lift, were seen. The owner reported that all necessary service contracts are maintained. There was documentary evidence of appropriate hygiene procedures being followed in the kitchen. It was reported that all staff are trained in moving and handling techniques by an internal facilitator. It was also reported by the manager that there is always at least one member of staff on duty who is trained in first aid. The manager reported that there were always supplies of disposable gloves and aprons and that staff were required to use them to minimise the risk of cross infection. The staff member who was interviewed confirmed this to be true. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 19 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 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 Requirement The registered person must ensure that the home’s medication procedure is rigorously followed. The registered person must ensure that an annual development plan is produced, taking into account the views of service users. Timescale for action 01/05/06 2. OP33 24 01/07/06 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 OP16 Good Practice Recommendations The registered person should ensure that concerns or complaints are recorded and monitored, even when they are not a ‘formal’ complaint. Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fernbank DS0000005506.V280437.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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