Inspection on 23/01/07 for Ferncliffe Road

This inspection was carried out on 23rd January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferncliffe Road 27/01/06

Ferncliffe Road 31/08/05

Ferncliffe Road 11/01/05

Ferncliffe Road 27/08/04

Ferncliffe Road 31/03/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Ferncliffe Road 19 Ferncliffe Road Leeds West Yorkshire LS13 3PH Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 23rd January 2007 10:30 Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 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 Ferncliffe Road DS0000001450.V322644.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 Adults 18-65. 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. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferncliffe Road Address 19 Ferncliffe Road Leeds West Yorkshire LS13 3PH 0113 2557443 0113 2557443 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) www.c-i-c.co.uk. Community Integrated Care *** Post Vacant *** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: Ferncliffe is a single-storey purpose built home situated in Bramley. It has a large enclosed garden to the rear of the building. A car parking area is located at the front of the building. Local shops and Bramley town centre are within easy access. Ferncliffe Road is part of the Community Integrated Care organisation, and is registered to provide personal care for up to 4 people with learning disabilities. The accommodation consists of four single bedrooms, a lounge and separate dining room, shower room and bathroom, laundry, and a domestic style kitchen. All laundering is undertaken on the premises. The home has a vehicle, which is utilised by service users on a regular basis. The range of fees charged was not available therefore it has not been possible to publish how much a placement costs per week. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in January 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. A comment card was received from a healthcare professional and their response has been included in the report. One inspector carried out a site visit which started at 10.30am and finished at 5.30pm. Feedback was given to the deputy manager a few days after the inspection. During the visit the inspector looked around the home, observed staff and service user relationships, spoke to service users, staff and the manager. Service users living at the home have profound learning disabilities and discussions with service users were very limited, therefore observation of staff contact and communication was an important part of the inspection. Service user plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. Each service user should be provided with information about how much their placement costs per week and who is responsible for paying for the placement. Fees will vary. Details of the fees charged were not provided with the pre inspection questionnaire and only the cost of one placement was available in the home. The cost for this one placement was £1011.52 per week. What the service does well: Everyone has a very different lifestyle that is based on their needs and preferences. Service users have a care file that contains a lot of information about how their care needs should be met and what is best for the individual. Staff know the service users well and were able to recognise signs when they were happy and unhappy. Staff and management involve other professionals and seek advice to make sure service users are getting the right healthcare. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 6 The home is pleasant, reasonably well maintained and service users are comfortable in their surroundings. The organisation is good at making sure staff have opportunities to attend training courses. What has improved since the last inspection? What they could do better: The Statement of Purpose should be reviewed and amended to ensure people are provided with accurate information. Service users should be provided with information about how much their placement costs. The organisation has been asked to provide this since June 2003 but they have failed to do so. Some information in the care files was out of date and some care needs had not been properly assessed, which could result in care needs being overlooked. Service users pay for a vehicle but there were no records about how much they have to pay. The vehicle has not been used much recently and because of the lack of drivers service users sometimes have to use and pay for taxis. This system must be looked at to make sure payments are fair and service users are getting value for money. Meals are not healthy and nutritionally balanced. In the three week period leading up to the inspection service users had been given fourteen meals that consisted of either fish and chips or pastry based dishes such as pie. The home has one bath and this has been condemned, therefore service users cannot have a bath. Two service users can have a shower but others can’t. The organisation was first made aware there was a problem with the bath in July 2006, and it has been out of use since November. The kitchen units also need replacing. Some potentially dangerous creams and lotions were not locked away and these could pose a risk to service users. On occasions, staffing levels have not been satisfactory and this has affected the quality of the service. The manager only works at the home part time and there are no other appropriate management arrangements in place. This has led to some management decisions being made by support staff. Requirements and recommendations that were identified at this inspection are at the end of this report. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 7 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. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Previous inspections and procedures indicate that a thorough admission process would be carried out before service users could move into the home. However, the organisation has failed to provide a record of the care home’s charges and amounts paid by or in respect of service users. This is a breach of regulations and prevents service users or their representatives from having access to information which they are entitled to see. EVIDENCE: No service users have been admitted to the home since 2003, therefore there was very little recent evidence available for many aspects of this outcome group. The admission process was looked at during previous inspections and the relevant National Minimum Standards were met. The statement of purpose provided information about the home but it contained details that were a year out of date. Each service user should have been issued with a statement of terms and conditions and information about how much is charged for each placement. The manager could only find details for one service user that provided information about the cost of the placement. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 10 A requirement has been made at each inspection to provide information about fees since June 2003. The Care Homes Regulations state service users must be provided with details of the total fee payable in respect of the service they receive. The pre inspection questionnaire asks for information about the current scale of charges but this was left blank. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive individualised care but to make sure everyone is receiving the right support care planning must be an ongoing process. Staff work hard to make sure decisions are made in the best interests of service users but are let down by the documentation. EVIDENCE: Each service user has several different documents that provide information about their care needs. Documents describe what service users like and dislike, how their needs should be met and potential risks. They also had details of people that were important to the service user. For example one care plan stated ‘my mum is important to me and when she comes we sit and chat’. Another care plan stated ‘I like boiled eggs on a morning’, and the breakfast menu confirmed that the service user was offered boiled eggs This is good practice and demonstrates that staff and management have worked hard to find out how they can provide the best care to each service user. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 12 Staff had very good knowledge of service users and their individual care needs. They were able to provide very specific details about how they looked after each service user and recognised signs when service users were unhappy. Care plans had good information about identifying when service users were happy and unhappy. Staff said the organisation was good at promoting person centred care. Although the original information was very good, staff have struggled to keep the information up to date. Several pieces of information were out of date and the guidance on how service users needs should be met was no longer relevant. One service users needs had changed dramatically in the past two years but a ‘My Life’ book had not been updated since September 2005, therefore if this was read as a guide by an agency staff or a new staff member they would be misguided. Another My Life book was not dated but the manager said the information was reasonably up to date. Keyworker details were out of date. Some risk assessments were no longer applicable and other obvious risks had not been assessed. One care plan had been re written in December 2006. Another care plan had not been reviewed since April 2006. Some very important areas of need had not been included in one care plan and risks had not been assessed and these details have been written in the health and personal care section. The manager talked about plans to reorganise the care documentation for each service user because they have identified that there is too much information in the files and staff would be unable to pick up the files and find the information to support service users. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Everyone has a different lifestyle, which is based on their needs and preferences, although this could be improved if there were more opportunities to go out. Service users are not getting value for money in terms of transport because they pay for a vehicle which is not used as regularly as it used to be and they also have to pay for taxis. Service users health and wellbeing is being put at risk because they do not receive a well-balanced and nutritious diet. EVIDENCE: Staff said they thought the home provided good care and opportunities for services users to lead lifestyles that are determined by individual preferences. For example one service user enjoys being actively involved in the kitchen and staff make sure they have plenty of opportunities to do so, whereas another service user requires much more relaxation time. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 14 Daily records for the last four weeks were looked at for two service users. They had both had opportunities to go out and had participated in recreational activities, although these had not been on a regular basis. One evening a week a music therapy session is provided in the home. Staff said all service users enjoyed attending. Two service users attend external day services. The inspection identified some problems with staffing levels which have affected the service users quality of life. These details have been written in the staffing section. Three service users went on holiday with staff during 2006. Staff said service users enjoyed and benefited from the holidays. The home has a minibus and people at the home make a financial contribution but the manager did not know how much they paid. No financial records that related to the vehicle were available in the home. The manager and staff acknowledged that there were only a few people that could drive the vehicle and therefore there were occasions when it could not be used and service users had to pay for a taxi. Two service users use the vehicle very occasionally. Transport records do not identify which service user have travelled in the vehicle. The cost of the vehicle for service users should be reviewed to make sure it is equitable and they are getting value for money. Four weekly menus were available but daily food records confirmed that these were not being followed. Breakfast choices were varied and staff said these were based on individual preferences. Food records for the last three weeks were looked at. During this period, service users had been given fourteen meals that consisted of either fish and chips or pastry based dishes such as pie. This is not a healthy and nutritionally balanced diet. Care staff are responsible for preparing and cooking meals. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support is poor because service users cannot have a bath in the home. Systems are in place to make sure residents receive the right support from healthcare professionals but they need to improve the recording of how they monitor healthcare at the home to make sure all health needs are being properly monitored. EVIDENCE: Daily records and health care records stated that service users received regular input from external healthcare professionals. Outreach workers, district nurses a chiropodist and optician had visited. Staff said they thought the home was good at consulting healthcare professionals when they wanted advice and support. One daily record stated that staff had consulted a GP for advice when they had concerns about medication. This is good practice. A GP comment card stated they were satisfied with the overall care provided to service users. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 16 Care plans and health records again provided a lot of very specific key information but there was information that had not been up dated. Weight records for two service users were looked at. One service user did not have a weight record for 2006 but had been weighed in 2007. The manager said they had had difficulty in accessing wheelchair scales. Another service user was weighed in March 2006 and again in May 2006, and there had been a weight loss of over 1 stone. The weight record had not been filled in after this date and there was no care plan or risk assessment that referred to how the weight loss should be monitored or managed. Two service users have only been able to have a bed bath for nearly three months because the bath was condemned at the beginning of November 2006 and they cannot access the shower room. A problem with the bath was first reported to CIC in July 2006. The care records for one of the service users stated, ‘If I could do anything on a morning, what would I do? Have a bath’. This is unacceptable and very poor practice. The manager said facilities at another home were available but also acknowledged these would not be appropriate. There were some clear health and personal care gaps in the care planning process. One service user had recently had some pressure sores and the district nursing team had visited on a regular basis. The service user did not have a care plan or risk assessment for pressure care. The home’s pressure area care policy stated that an assessment and care plan should be completed. The service user was also regularly helped to eat in bed but again this information was not in the plan of care and had not been risk assessed. Medication records were looked at and had been completed correctly. No controlled medication was held at the home. Medication storage was looked at and this corresponded with the medication records. One service user has their medication mixed with their drinks. This has been discussed and agreed with the GP. The manager does a monthly medication stock check. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures are in place to protect service users. Systems are in place to make sure finances are safeguarded. EVIDENCE: The manager said the home had not received any complaints within the last twelve months. The home has a book to record any complaints. The home’s complaints procedure was displayed in the home, although the telephone number of the Commission was not included. Staff said they would talk to the manager if they had any concerns. Staff have recently attended adult protection training and were familiar with adult protection procedures. Financial records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant, reasonably well maintained and service users are comfortable in their surroundings. EVIDENCE: A tour of the building was carried out. All bedrooms, communal areas and bathrooms were visited. The home was clean and tidy and there were no odours. Decoration, furniture and furnishings were of a reasonable standard. The garden was well maintained and a pleasant area that service users could safely use. Service users walked freely around the home and used all communal areas. Bedrooms were personalised and each room had items that reflected individual preferences. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 19 As stated earlier in the report the bath has been condemned. Service users still use the toilet in the bathroom. During the tour it was noted that a number of prescribed items were left on a shelf in the bathroom. These included, Corsydyl mouthwash, Diprobase lotion, Kepotine shampoo, Elocen cream and Balneum bath oil. The manager must ensure items that could pose a risk to service users are locked away. The bathroom and one bedroom have overhead tracking and a mobile hoist is provided for use in communal areas. There was a supply of disposable gloves, wipes, anti bacterial hand wash and paper towels throughout the home. The laundry had an industrial washer with a sluicing facility and a dryer. The organisation has sent monthly reports to the Commission on the conduct of the home, and these have identified that the home needs a new kitchen and carpets and some areas need decorating. This is good practice and demonstrates that the environment is being properly monitored. It is important that the kitchen is replaced as a matter of urgency because the edgings on several kitchen unit doors and handles were damaged, therefore they could not be properly cleaned to prevent the spread of infection. One toilet on the ground floor was being used to store equipment, which included pads and Christmas decorations. Anyone who wanted to use the toilet would have difficulty getting to the toilet or sink. This is not appropriate because a room with a toilet is not a suitable environment to store equipment. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On occasions, staffing levels are not satisfactory and this affects the quality of the service. Systems are in place to make sure staff are properly recruited and everyone receives the right training for the work they are to do. EVIDENCE: On the day of the inspection two staff were working on shift although there should have been three. One staff had given notice that they would not be at work but the shifts had not been covered. Only one staff was on duty between 7am and 9am. This had also happened the previous day. One service user should have gone horse riding but this was cancelled because of the staffing levels. Staff confirmed this had happened before. One service user’s care record stated I go out shopping if we have enough staff. There have also been occasions when only one member of staff has been on duty between 2pm and 4pm. Staff said service users do not go out as often as they have in the past and this was because of staffing levels. Staff also said they no longer tend to plan activities. The manager agreed outings are less frequent. Staff also said Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 21 morning shifts were very busy if only two staff were on duty. One staff said there was a ‘big difference’ if three staff were on duty and there were more opportunities to organise outings and have quality time with service users. Another staff said all the service users love one to one time with staff but it was difficult when only two staff were on duty. The manager said the minimum staffing levels should be three staff on the early shift and two staff on the late shift and night shift. The minimum staffing levels were not being followed which meant service users diverse needs were not being met. There were several staff vacancies and the organisation was having difficulty filling the posts. Staff said the vacancy factor was a problem because agency workers didn’t know the service users or the routines of the home. Staff acknowledged the organisation was trying to recruit. There were some issues relating to staff and management roles and responsibilities. These details have been written in the Management section. During the past twelve months staff supervision has been sporadic but the manager has recently reintroduced a formal supervision programme and all staff have started to receive regular supervision. Team meetings are held regularly. Only one staff member has been recruited in the last twelve months. These recruitment records were looked at and all the relevant information was available. The staff member confirmed she had a good induction programme when she started working at the home. The Pre Inspection Questionnaire stated that all mandatory training was up to date. Staff said the organisation was good at making sure all staff had opportunities to attend training courses. One member of staff said the training regime was very good. Two staff have completed National Vocational Qualification (NVQ) level 2 or equivalent Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has made some good improvements but because management arrangements are not satisfactory staff are making decisions that are not within their remit. Service users live in a safe environment. EVIDENCE: There has not been a registered manager in post since January 2006. The current manager is registered and responsible for the management of another home at the other side of the city, spending three days in the home one week and two the next. The only other management hours allocated to Ferncliffe Road are a 37 hour senior post. Staff said the home would benefit from more management hours. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 23 All other staff are employed as support workers but have been involved in making management decisions. On the day of the inspection staffing levels were short. The manager said she was not aware that support staff had made the decision not to arrange additional cover. Most shifts consist of support workers and there is not an identified person responsible to lead the shift. Decision-making, finances and medication duties are shared. The registered provider must ensure that staff have a clear understanding of their own and others’ roles and responsibilities and there are appropriate management arrangements in place to ensure the home is well managed in her absence. The home has gone through some management changes within the past twelve months and this has caused some difficulties. Staff and the manager all felt there had been some recent improvements that had helped build staff morale and improve teamwork. Staff said the manager has made positive changes but there was still work to do to before everyone was working in the same direction. One staff said it was better because there was more freedom to do things with service users, another staff said staff morale was on the up. Daily records generally provided enough information about what each service user had been doing but some were vague and did not give a clear picture of what had taken place. For example, ‘all cares given’, ‘demanding of staff’, and ‘a few outbursts with staff’. Sufficient information should be recorded that enables service users health and welfare to be properly monitored. Once a month the area manager visits the home and looks at the general conduct, these visits are called Regulation 26 visits. The manager confirmed the visits were completed regularly. Copies of reports from these visits are sent to the CSCI. The manager said the organisation had sent quality monitoring surveys to relatives and staff but she did not know the outcome of the surveys and could not locate the information. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 3 X 2 X 2 3 2 3 X Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 25 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 YA5 Regulation 5 Requirement The registered person must ensure service users have a statement of terms and conditions and a record of the current range of fees must kept in the home. (Timescales of 1st September 2006, 31st March 2005, 30th November 2004, 29th February 2004 and August 2003 not met) The registered person must make sure service user plans are kept under review and information should be accessible. The registered provider must review the transport arrangements to make sure charges to service users are recorded, equitable and value for money. The registered person must provide suitable and nutritious food. The registered provider must make sure service users personal care needs are met. This relates to the provision of suitable bathing facilities. The registered person must DS0000001450.V322644.R01.S.doc Timescale for action 31/03/07 2. YA6 15 31/03/07 3 YA13 17 12 16 31/03/07 4. 5. YA17 YA18 16 12 23 28/02/07 28/02/07 6. YA19 12 28/02/07 Page 26 Ferncliffe Road Version 5.2 13 7. YA24 13 8. 9. YA24 YA33 23 18 10. YA37 10 17 18 make sure service users health care needs are assessed and monitored. This relates to pressure care, helping to eat in bed and weight. The registered person must make sure items that could pose a risk to service users are locked away. The registered person must ensure the kitchen is in a good state of repair. The registered person must ensure there are sufficient staff working at the home to meet service users assessed needs. The registered person must make sure the management arrangements are appropriate to the home. The registered person must ensure staff and management responsibilities are clearly identified. The registered provider must ensure an application for the registered manager is submitted to the CSCI The registered person must make sure the home has an effective quality monitoring system. 28/02/07 31/05/07 28/02/07 31/03/07 11. YA37 9 30/04/07 12. YA39 24 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA13 Good Practice Recommendations The statement of purpose should be kept under review. The registered person should look at developing the level of recreational activities. DS0000001450.V322644.R01.S.doc Version 5.2 Page 27 Ferncliffe Road 3. 4. 5. 6. YA22 YA24 YA32 YA41 The registered person should include the Commission’s telephone number in the complaints procedure that is displayed in the home. The registered person should make sure equipment is stored appropriately. The registered provider should work towards achieving the 50 target of care staff holding a NVQ level 2 award or equivalent. The registered person should make sure there is sufficient recorded detail to monitor service users’ health and welfare. Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Ferncliffe Road DS0000001450.V322644.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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