Inspection on 20/07/06 for Ferndale

This inspection was carried out on 20th July 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferndale 24/06/08

Ferndale 21/02/06

Ferndale 29/11/05

Ferndale 18/02/05

Ferndale 10/08/04

Ferndale 11/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ferndale 131 Whitstone Road Shepton Mallet Somerset BA4 5PS Lead Inspector David Kidner Key Unannounced Inspection 20th July 2006 10:30 Ferndale DS0000016293.V298778.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 Ferndale DS0000016293.V298778.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. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale Address 131 Whitstone Road Shepton Mallet Somerset BA4 5PS 01749 345885 01749 345197 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) THE ORCHARD VALE TRUST MR MELVYN PHILLIPS Care Home 2 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 2 PERSONS IN CATEGORIES LD AND MD Date of last inspection 21st February 2006 Brief Description of the Service: Ferndale is registered with the Commission for Social Care Inspection to provide care for two service users who have a learning disability. It is a small home located in a residential area of Shepton Mallet. To the ground floor is a utility area, a domestic style kitchen/diner with patio doors leading to a large rear garden with a patio and lawned area. Both service users have a personal lounge on the ground floor. Bedrooms are located on the first floor and one service user has their own en-suite facility, there is also a family type bathroom. The Registered Manager is Melvyn Phillips. The Registered Provider is Orchard Vale Trust, a non-profit making company and a registered charity. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted this Key Unannounced Inspection over one day (6hrs). The Inspector viewed records in relation to care plans, risk assessments, health and safety, the management of medicines, staff recruitment and viewed all parts of the home. On the day of the inspection both service users were at home but there were plans to go out for the day. Therefore, due to the needs of the service users and not wanting to disrupt their day, the Inspector had minimal contact with the service users but was able to gain a judgement on the service that is provided at Ferndale. The Inspector was able to have some discussion with both service users and observe how staff interacted with them. The Inspector spoke to three staff, one in private and observed care practices. The Registered Manager and Deputy Manager were present throughout the inspection. As part of the Inspection process the Inspector sent Relatives/Visitors comment cards to two relatives. Both were returned, and comments were very positive and stated that they were satisfied with the overall care provided. Comments cards were sent to both care managers, one was returned. Feedback was also received from the GP. Again, comments were positive and stated that they were satisfied with the overall care provided at Ferndale. The Inspector would like to thank the service users and care staff for making the Inspector feel welcome at the home and their contribution in the inspection process. As a result of this inspection the home has one requirement and five recommendations. What the service does well: Ferndale provides a very homely environment that focuses on providing the service users with a safe environment that promotes empowerment, decisionmaking and choice. Service users have individual lounge areas that enable them to live in the lifestyle that they so wish. Care plans and record keeping is of a high standard. Activities are based on personal likes and choices and the staff are very pro-active in supporting service users to access all community based facilities. A consistent approach and continuity of staff promote good practices in relation to the management of behaviours. The Registered Manager and care team are committed in providing a high quality service Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 6 Care plans and record keeping is of a high standard. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 7 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 Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome is Good. The home conducts detailed pre-admission assessments prior to any service user being considered to move to Ferndale. EVIDENCE: There have not been any admissions to the home for a number of years. Therefore, the Inspector was not able to fully assess Standard 2 of the National Minimum Standards. However, the Inspector was advised that a detailed preadmission would be completed as in line with Orchard Vale Trust policies and procedures. Careful consideration would be needed as to how any a prospective service user would be introduced to the home and the need to seek the views and opinions of any service user living at the home at that time. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 The quality outcome is Good. The care plans are very detailed and are reviewed on a regular basis. The home had developed very good systems for behaviour management. There is clear evidence service users being offered choices in day to day living based on detailed risk assessments. EVIDENCE: The Inspector viewed one care plan in detail. The care plan was detailed and contained vast information as to how the service supports the service user in relation to the management of their behaviours. The care team supports the service users within a low arousal environment. The care plan is presented in different sections and it was noted that staff had signed their awareness of management guidelines, behavioural support plans and risk assessments. Behaviour analysis records were present and outcome strategies implemented where needed. The Registered Manager stated that physical intervention has not been used at the home for approximately 2yrs. This is very positive. The Inspector viewed Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 10 documentation in relation to proactive and reactive strategies that had been agreed and reviewed by the care team, parents and care manager. It was also noted that the care plan contained detailed information about communication needs, activities, and visits to health care professionals and evidence was seen that the plan had been reviewed at regular intervals. The Inspector and Registered Manager discussed the format in which the care plans are presented. It is recommended that the format in which the care plans are presented are reviewed to ensure that they are more user friendly, accessible and where appropriate signed by the service user. This is not a criticism of the current format of the care plans as considerable effort has been employed to ensure a detailed care plan has been developed. Currently the home manages the service users finances on their behalf. Each service user has a bank account with three monthly statements provided. Benefits are paid directly into the service users accounts. The home keeps detailed records of expenditure including receipts. The Inspector sampled both service users finance records. It was noted that both service users finances were not kept individually and both monies are ‘pooled’. It is recommended that service users monies are kept separately as this will aid the audit trail and promotes individuality. The home balances each finance record on a monthly basis. The Inspector was not able to trace the receipt for one entry. The receipt may be stored with other financial records at the home. The Inspector also discussed how the service users are supported to access their finances. The service users could keep their individual tins. The Registered Manager is pro-active in ensuring service users are protected from financial abuse, however the Registered Manager must review the homes policies and procedures to ensure that the manner in which finances are accessed and recorded are robust, including robust audit trails. The Inspector noted that at the time of the inspection service users were offered choices in day-to-day living. Any restriction on choice is limited by the individual’s own understanding or through the risk assessment process. Risk assessments are detailed to ensure that key triggers to behaviour that challenges the service are acknowledged and minimised wherever possible. They are reviewed regularly. Risk assessments that the Inspector viewed included assessments for accessing various activities and daily life skills. Currently Advocacy services are not accessed as it if considered not necessary at present. Staff that the Inspector spoke to stated that service users are given as much choice as possible. including menu planning, shopping, going to bed and getting up, personal routines and day to day living. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 11 Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 17 The quality outcome is Good. Service users are supported to access a variety of social and leisure opportunities based on individual need and preferences. The home encourages contact from relatives and friends. Service users are fully involved in the planning of the menus. EVIDENCE: The Registered Manager and staff spoken with confirmed that the service users have access to a variety of social, leisure facilities and access local community facilities. These include; local shops, supermarkets, restaurants, swimming pool, pubs, local health club and visits to Stately Homes. All such activities are recorded in the daily individual personal records. There are good relationships with the local neighbours. One service users access art therapy and pottery therapy and has some of their work displayed in their lounge area. Service users also access music therapy. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 13 The Inspector sent comment cards to both service users relatives. The feedback received was very positive. Comment cards confirmed that the relatives are made to feel welcome at the home and that they can visit their relative in private and that they are kept informed of important matters that affect their relative. Service users have appropriate locks fitted to their bedroom doors to promote privacy. On the day of the inspection it was noted that staff were speaking to service users in a courteous and professional manner. Staff were observed to be offering service users with choices and were encouraging service users to make decisions for themselves. The home does not have set menus, as the service users are fully involved in menu planning and shopping for food for the home. Service users choose what to eat on a day-to-day basis with individual preferences, likes and dislikes taken into consideration. A brunch is usually taken of a morning and a small snack at lunchtime with a main meal at night. However, service users can access snacks and drinks at any time of the day. The care staff take meals with the service users staff are aware of healthy eating and nutritional requirements and will support and guide the individual service user towards a health lifestyle. It was noted that there was a large bowl of fresh fruit in the kitchen/dining area and fresh vegetables in the home. Food cupboards and freezers appeared well stocked. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 The quality outcome group is Good. Care plans detail the care and support that is needed and service users are supported in ensuring their health and emotional needs are met. The home manages medicines well at the home but needs some improvement. EVIDENCE: As previously stated the care plans identify the manner in which the service users wish to communicate and receive the care and support based on individual need. The Inspector noted that the service users were offered support and guidance in a professional manner based on their wishes and needs. Service users require minimal support in meeting their personal care needs. One service user has an en-suite facility and the other service user has the use of the main bathroom. This further promotes privacy. There are no fixed-times for service users to go to bed or to get up of a morning. Staff spoken to confirmed this at the time of the inspection. The Inspector noted that the service users were very well attired and presented themselves in a very positive manner. No specialist aids and adaptations are required at the home. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 15 Physical and emotional needs are detailed in the care plans. Records viewed evidenced that service users have regular health care checks from the GP when needed and regular visits to optician and the dentist. Service users have access to other professionals including Consultant Psychiatrist and psychologist if and when required. The Inspector viewed the records kept in relation to the management of medicines at the home. MAR sheets were well maintained, however the Registered Manager should ensure that two staff signatures support any hand transcribed medicines. The home has a medicines returns book and a homely remedies policy. The Inspector recommended that the homely remedies for each service user should be signed in agreement by the GP. Discussions took place in relation to service users managing their own medicines based on individual assessment and detailed risk assessments. The Registered Manager commented that this would be given further consideration. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 The outcome group is Good. The home has a detailed complaints procedure. Service users are safeguarded by the homes policies and procedures, however the home must ensure that policies and practices relating to service users finances are robust. EVIDENCE: The home has a complaints procedure that includes the contact details of the Commission for Social Care Inspection (CSCI). The home or the CSCI has not received any formal complaints or concerns since the last inspection. The feedback received from the comment cards was that all were aware of the homes complaints policy with the exception of one feedback comment card. This was discussed with the Registered Manager at the time of the inspection who advised that he would ensure that all interested stakeholders are aware of the Complaints Policy. The home has policies and procedures in relation to the protection of vulnerable adults. Including physical intervention, risk assessment, adult protection and the management of service users finances. The Inspector viewed very detailed documentation in relation to behaviour management. The home has not used physical intervention for approximately 2 years. There were risk assessments, behaviour management guidelines and behaviour analysis. ‘ Contracts’ to address how service users manage their behaviours have been developed to meet individual needs. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 17 Each service user has a bank account with three monthly statements provided. Benefits are paid directly into the service users accounts. The home keeps detailed records of expenditure including receipts. The Inspector sampled both service users finance records. It was noted that both service users finances were not kept individually and both monies are ‘pooled’. It is recommended that service users monies are kept separately as this will aid the audit trail and promotes individuality. The home balances each finance record on a monthly basis. The Inspector was not able to trace the receipt for one entry. The receipt may be stored with other financial records at the home. The Inspector also discussed how the service users are supported to access their finances. This should be reviewed to ensure that this process is robust. Ferndale DS0000016293.V298778.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 The quality outcome is Good. Ferndale provides a high standard of accommodation and reflects individual needs and preferences. Bedrooms are personalised and meet individual needs. The home was clean and hygienic on the day of the inspection. EVIDENCE: The Inspector viewed all areas of the home. Ferndale is very domestic in style and the care team have worked hard to ensure that the home is kept as domestic and family like wherever possible. The home has a good sized kitchen/diner, utility room, two separate lounge area, two service users bedrooms, one en-suite, a family type bathroom and a bedroom that is used as a staff sleep in facility and ‘study’ area. Each service user has a lounge area that has been decorated in the style and preference of each service user. Both lounge areas are decorated and maintained to a high standard. Service users choose the furnishing and fitting with staff support where needed. One lounge area has pictures and items of pottery that the service user had made. Each lounge area has a TV, video, Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 19 DVD player and hi-fi as chosen by the service users. These areas appear very homely and individual. Both bedrooms are also decorated and furnished to meet the needs of the service users. Again, the bedrooms are decorated to a high standard and reflect the needs of the service users. One service user has full en-suite facilities. There is a family style bathroom that is used by the other service users and care team. The home has a facility on the first floor that may provide staff with showering facilities. If this was the case the other service user will have exclusive use of the family type bathroom. The Inspector recommends that this be given further consideration as part of the home’s planned refurbishment and redecoration programme. The home has a large rear garden that has a patio area, fishpond and lawn area. Both service users enjoy gardening. There is a large parking area to the rear of the home that is used as a staff car parking facility. There is a small parking area to the front of the property that is used for the service users. There is a small laundry/utility area that accommodates the fridge/freezer and a downstairs toilet. On the day of the inspection the home was clean and hygienic. Ferndale DS0000016293.V298778.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 The quality outcome is Good. Service users are supported by a competent and effective staff team. Staff are provided with appropriate training, however, the home needs to promote the use of NVQ to provide staff with formal qualifications. The homes recruitment process is robust. EVIDENCE: Ferndale has a small staff team that provides a consistent approach to the care of the two service users. The home works closely with a ‘sister’ home located a few miles away and will provide staff in times of annual leave and sickness. This ensures that continuity and consistency for the service users is paramount. The Inspector viewed the main staff rota matrix that identifies who will be working at the home depending on service users day to day planned activities and needs. The home has a core group of four staff excluding the Registered Manager. The Registered Manager is very much hands on and works shifts at the home. It appears that there is usually three staff employed during the day and one staff at night, depending on need. One staff member sleeps in. There are no waking staff required, however, there is an on-call system. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 21 The care staff the Inspector met appeared to be very motivated and enthusiastic. Staff demonstrated a clear understanding of the needs of the service users and stated that they were aware of the care plans and the manner in which they are to be implemented. Care staff complete daily monitoring sheets with regards to the service user care and support. These records are developed to establish patterns of behaviour. Such records are also discussed at staff supervision to ensure appropriate care and support is given. This is good practice. Staff have received training in the management of aggression from the Registered Manager and at Induction. Staff have also received training in first aid, food hygiene and moving and handling. The Registered Manager has noted that some staff require refresher training and is addressing this matter. The Inspector had discussions in relation to staff receiving formal training to achieve NVQ qualification. Currently, no members of staff have an NVQ qualification. The Inspector recommends that this is reviewed and an action plan is forwarded to the CSCI to address this matter. The Inspector viewed the documentation in relation to the most recently employed member of the care team. The recruitment file contained the required documentation as required in Schedule 2 of The Care Homes Regulations 2001. This was a requirement at the previous inspection. The home has recently reviewed how the service access training opportunities for all staff. It was noted that staff working at Ferndale have received training in food hygiene, moving and handling and first aid. Each team member has detailed records of training that has been undertaken. The home is very proactive in ensuring that they have a well-trained workforce. The Registered Manager advised that the home will be accessing distance learning form a training provider for such training as fire safety, moving and handling, risk assessment, medicines, POVA, first aid and Induction units. Ferndale DS0000016293.V298778.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 The quality outcome is Good. Ferndale is a well run home. Good quality assurance and quality monitoring systems have been devised. The home strives to promote health and safety. EVIDENCE: The Registered Manager is Melvyn Phillips. Melvyn has a formal nurse qualification (RNMH), is also an Applied Psychology Graduate and has an NVQ 4 in management and has approximately 20 years experience in working with people with learning difficulties. Melvyn ensures that he keeps himself well informed and aware of best practice by attending refresher courses and appropriate conferences. The home is very pro-active in ensuring that it has good quality assurance and quality monitoring systems. Internal audit systems have been developed such Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 23 as daily service user recording sheets, activities, domestic cleaning, medicines and finances. The home does not conduct service user meetings, as this does not seem appropriate. Staff seek the views of the serviced users on a daily basis. The Registered Provider conducts Regulation 26 visits. The Registered Manager advised that there is excellent communication with all appropriate members of the service users family and other interested stakeholders. There are quarterly Trust Families meeting with access to the Chairman, Council Members the Chief Executive and Managers. The home maintains a comment book. This was not viewed at the time of the inspection. Due to the size and nature of the service it is felt that formal service users and interested stakeholders surveys are currently not appropriate. Following a tour of the premises, the following records were examined relating to the health and safety of service users, staff and visitors to the home. FIRE SAFETY – The fire system was due to be serviced on 23/08/06. The home has forwarded a copy of the certificate to confirm that this has been conducted. Weekly checks are conducted on the fire alarm system. The last recorded test was on the 19/07/06. The emergency lighting is tested monthly as well as the homes torches. The last fire drill was conducted in June 2006. The fire equipment was serviced on 30/06/06. Staff have received regular fire training and it was suggested that a fire training matrix is developed to easily identify that staff have received this training. There is no smoking in the home. RISK ASSESSMENTS – So as to further promote health and safety, the home must conduct detailed risk assessments in relation to window restrictors being fitted to first floor windows and wardrobes being secured. The Registered Manager will be completing environmental risk assessments as needed. ELECTRICAL SAFETY – Portable Appliance testing was conducted in August 2006. No failed appliances. The Electrical Hardwiring Certificate is dated 19/06/06. However, the overall assessment was unsatisfactory. The Registered Manager has stated that the work to address this is due to commence on the 18/09/06. LEGIONELLA – A health and safety risk assessment has been completed the hot water is set at 70 degrees centigrade with thermostatic valves fitted to all hot water outlets. Regular checks are conducted on hot water temperatures with records kept. HOT WATER- The home maintains weekly monthly records of the temperature of the hot water outlets. GAS SAFETY – The home’s annual gas safety certificate is dated 22/11/05. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 24 ACCIDENTS – Records viewed indicated that there have been no service users accidents since the last inspection. There have been two recorded staff accidents since the last inspection. FIRST AID – Training records seen at this inspection indicated that all staff had received up to date training in First Aid. FOOD SAFETY – The Inspector was informed that staff involved in the preparation of food have an appropriate food hygiene certificate. Staff training records seen by the inspectors confirmed this. The home keeps daily records of fridge and freezer temperatures. Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Ferndale DS0000016293.V298778.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? 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 YA42 Regulation 12 (1) (a) Requirement The Registered Manager must conduct risk assessments in relation to window restrictors being fitted and wardrobes being secured. Timescale for action 31/08/06 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 YA6 Good Practice Recommendations The Registered Manager should review the format in which the care plans are presented to ensure that they are more user friendly, accessible and where appropriate signed by the service user. The Registered Manager should ensure that individual service users homely remedies are agreed by the GP and two staff signatures support hand transcribed medicines. The Registered Manager should review how service users are supported to access their finances to ensure the process is robust and review the manner in which individual personal monies are stored. The Registered Manager should consider providing staff with separate shower facilities as part of the home’s DS0000016293.V298778.R01.S.doc Version 5.2 Page 27 2. 3. YA20 YA23 4. YA24 Ferndale 5. YA32 refurbishment and redecoration programme. The Registered Manager should submit an action plan to the CSCI to address the need for 50 of the care team to achieve an NVQ qualification. 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