Inspection on 24/05/07 for Ferndale

This inspection was carried out on 24th May 2007.

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

Ferndale 25/01/08

Ferndale 17/11/05

Ferndale 23/06/05

Ferndale 14/12/04

Ferndale 08/06/04

Ferndale 19/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ferndale Easton Road Flitwick Bedfordshire MK45 1HB Lead Inspector Leonorah Milton Unannounced Inspection 24th May 2007 08.50 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 Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale Address Easton Road Flitwick Bedfordshire MK45 1HB 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) 01525 712650 01525 714169 BUPA Care Homes (Bedfordshire) Ltd Manager post vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: Ferndale is a purpose built care home that is registered to provide for thirty frail service users over the age of sixty-five who may also have dementia and/or physical disabilities. The home had been operated for many years by the local authority and transferred to the current proprietor BUPA Care Homes (Bedfordshire) Ltd ten years ago. The manager had been appointed two months before this inspection. The building had been significantly upgraded after the transfer and provides single room accommodation on three floors. The communal accommodation of three lounges and a large dining room is located on the ground floor. All of the lounges overlook a well-stocked and maintained garden. Toilets and bathrooms are located for convenient access throughout the building. The home is located within walking distance of Flitwick’s town centre and its amenities. Fees for accommodation were between £462 and £476 weekly. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care Inspection (CSCI) since the last visit to and public report on, the home’s service provision in November 2005. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 24th May 2007 between 08.50 and 17.15, were taken into account. The visit to the home included a review of the case files for three people living in the home, conversations with seven people, a visitor, five members of staff and the manager. Much of the time was spent with people in the communal areas of the home, where the daily lifestyle was observed. A partial tour of the building was carried out and other records were reviewed. The Commission had received thirteen responses, completed by people living in the home or their representative, to a questionnaire circulated prior to this inspection. These have been taken into account and reflected in this report. What the service does well: The building provided a safe and comfortable environment. Arrangements to maintain a safe place to live and work in were good. People spoken to confirmed that they felt relaxed in, and satisfied with their accommodation. The written feedback indicated that the majority were satisfied with their accommodation. Observation of the lifestyle in the home and conversations with people showed that their relationships with the home’s personnel were cordial. Whilst banter between members of staff and people was friendly and familiar, it never the less was respectful of peoples’ dignity and abilities to communicate. People passed much praise about the way in which their care needs had been met. “Couldn’t treat me better”, “Its like a five star hotel, only better because you get medical treatment,” “Staff understand me”. Members of staff were described as “Attentive”, “Kind”. The home had a core of staff who had worked in the home for a considerable time and were well acquainted with peoples’ needs and the homes day-to-day routines. Such continuity of care had contributed to the well being of people living in the home. “ I feel safe”. “You will never get a better place than Ferndale”. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 6 Most people were content with meals. On the whole favourable comments were passed about individual lifestyles and the flexibility of daily routines. People confirmed there were “no rules” and that they could “get up and go to bed and do what they liked.” 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. The summary of this inspection report can be made available in other formats on request. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 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 Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had based its assessment of a person’s needs on the respite care plan obtained from another home. The home had therefore not assessed whether there were any changes in need since that admission that it would be unable to meet. EVIDENCE: The statement of purpose seen at this inspection provided a detailed guide to the service. Responses to the questionnaire showed that ten of thirteen people felt they had received sufficient information about the service before admission to enable them to make an informed choice about moving into the home. One response indicated that the person felt they had not been given any choice about the decision to move into the home, “ I was offered a private room at Ferndale which I had to take”. The inspector unfortunately was unable to ascertain whether the circumstance of this admission to the home was in this person’s best interests because the response was anonymous. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 9 Three case files were reviewed. Two contained detailed pre-assessments of need that covered needs outlined by the National Minimum Standard and included the placing authority’s assessment. The file for a recent admission however indicated that the home had not carried out a through assessment before admission to determine that the home had the capability to care for this person. There had been no emergency circumstances governing this admission. The file contained a care plan from another home where the resident had stayed briefly during the previous month. The plan did not include a full assessment of need. The record for the pre-admission assessment of need carried out prior to admission to Ferndale was incomplete: no entry had been made on the document to indicate the person’s name, date of birth, date of assessment, or where the assessment had been carried out. Entries about needs were brief. The document was not signed or dated. The inspector was informed that this document/assessment had been completed on the day this person had been admitted the home. There was no assessment on file from the placing authority. The home provided respite care but not an intermediate care service. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient guidance was available to personnel to enable them to understand the needs of the people living in the home and how these were to be met. Assessments and guidance however had not established that at least one person had the capability to self administer medications. EVIDENCE: Three case files were assessed. The care plans seen were based on detailed assessments of need. Plans covered people’s personal, physical, health, recreational, social and emotional needs. Documents listing peoples’ preferences for their daily lifestyle had been completed. These listed preferred times for getting up and going to bed, preferred beverages, frequency for bathing, hairdressing and similar. Preferences for food were not recorded. There was however a detailed list in the kitchen of individual likes and dislikes and of any special dietary requirements. Records seen and conversations with people showed the home had taken appropriate steps to meet their health care needs. Records indicated that Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 11 appointments had been made for routine treatments such as chiropody and optical care and with their doctors as the need had arisen. Notifications to the Commission showed that several people had been infected with an infectious disease on two occasions this year. Records indicated that the home had liaised with doctors and the Public Health Department to eradicate these outbreaks. The manager reported that there had been noreoccurrence of the infection for the two weeks prior to this visit. Ten responses to the questionnaire had indicated they were “Always” satisfied with the arrangements for their health care. Three replied, “Usually”. Discussions with a senior member of staff who had the responsibility for overseeing the ordering, storage, return and administration of medicines showed her to be knowledgeable about safe practice. Observation of her practice during the administration of medicines before lunchtime showed that safe practice guidelines were followed. Assessment of the storage conditions for medicines showed that these had been properly secured in the designated medication room and when transported around the home. The records for the receipt, administration and return of medicines had been completed properly. The medication policy indicated that people would be supported to manage their medication where they had had been assessed as safe to do so. The relative of one person staying in the home for a respite period explained that they managed their medication as home and on return would continue to do so. During the stay at Ferndale however the home had taken control of this person’s medication. People confirmed that staff had treated them with courtesy. Care notes showed service users’ preferences for terms of address. One person said, “Its wonderful here. Staff are nice, attentive. I am very happy to be here.” This person described how they had been isolated and lonely in their own home and the treatment they had received from staff in the home, “I think they saved my sanity”. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst people had been provided with flexible daily routines, some people living in the home were not satisfied with activities for diversion, stimulation and entertainment. EVIDENCE: Information submitted by the provider showed a range of recreational activities, including regular visits from an external entertainer. A monthly religious service was held in the home that included communion. However the feedback from people living in the home about the daily lifestyle varied. Whilst the majority commented favourably on the relaxed atmosphere and the ability to get up and go to bed at times to suit the individual, there was some dissatisfaction with the arrangements for activities. The written responses to the question, “Are there activities arranged by the home that you can take part in?” showed three responses as “Always”, two as “Usually”, six as “Sometimes” and two as “Never”. Comments verbal and written included, “There is enough to do…an entertainer this week, community singing was really lovely”, “ There is plenty to do”, “ I am happy with the activities”, “I would like to see more interaction between staff and residents, such as time spent chatting to them. I would also like to see a few more organised activities”, “Activities, only when Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 13 the entertainer comes in”, “Some activities take place that are not of particular interest”. One person commented they “would like to smoke their pipe and have more then one glass of whiskey at a time”. People who contributed to the inspection visit confirmed that visiting times were not restricted and that their visitors were welcomed into the home. Notices indicated that visitors had been invited to attend organised activities. People living in the home had the right to hold their personal monies. Keys were available to lockable facilities in bedrooms for secure storage. However, in practice the majority of service users relied on their representatives to manage their personal finances. Whilst entry and exit from the home was restricted by the use of a key pad, the number was known by all those who wished to go in and out of the home. Service users stated that they were mostly satisfied with their meals. The survey indicated that six of thirteen people “Always” liked the meals, five “Usually” and two “Sometimes”. One described the food as “Top of the house”. Other comments included, “The food is fantastic”, “Food is nice”, “Food is alright. I enjoy it all”, “I think the variety/choice of meals could be improved”. Menus seen showed a nutritious choice throughout the day. The inspector sampled the meal served on the day of the inspection visit. It was tasty and well cooked. The cook and her assistant were aware of peoples’ needs and appetite, so that those who preferred smaller portions were not put off by larger servings of food. The cook was seen to go around the home to ask people about their preferences for lunch. She evidently was well known by the people living in the home and had established a good rapport with them. Special diets were catered for as required. Members of staff were observed to provide sensitive assistance to those service users who were unable to feed themselves. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home had robust protection procedures the home had not taken sufficient action to protect people because staff had not received formal training in these procedures. EVIDENCE: People who contributed to this inspection indicated that they felt able to raise concerns, “Staff are always prepared to listen”, and “I would tell a carer, my key worker, the manager”. One person said they knew how to make a complaint but “I have never needed to” and another said” “Seldom do I have a complaint”. Written responses showed that eight people “Always” knew how to make a complaint, three “Usually”, one “Sometimes” and one “Never”. Previous inspections had identified the home had robust written complaints and protection procedures. The home had recently properly notified the Local Authority and the Commission about allegations of physical and verbal abuse of person living in the home. These allegations were under investigated as this inspection took place. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 15 Three personnel files were assessed and showed that the home had properly carried out background checks via the Criminal Records Bureau and the Protection of Vulnerable Adults register (POVA) before personnel had been employed. These records showed however that none of these staff had received any formal training in adult protection procedures. The manager acknowledged that few personnel had received such training but stated that this was scheduled for the near future. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the building, its adaptations, décor and furnishings provided a suitable environment for frail older people. EVIDENCE: Feedback from people living in the home confirmed that they were mostly satisfied with the comfort of their surroundings, “My room is lovely. I feel confident because the call bells are within reach”, “My room is comfortable. Its kept clean and tidy”, “The home is always clean”, “ My bedroom is sometimes smelly and I am often cold”. The questionnaire showed that nine of thirteen people felt that the home was “Always” fresh and clean, three “Sometimes” and one “Never”. Areas of the building seen during the visit were clean and orderly. The décor throughout was mostly of an adequate standard. Given the numbers of Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 17 people living and working in this building some, there was inevitably some deterioration brought on by wear and tear. Areas of the corridors required repainting, paintwork/varnishing on doors and doorways were scratched and unattractive in appearance. The décor in one lounge looked most odd, as there was a missing section of wallpaper. The lock to one toilet door was not working properly. The outer layer of a toilet seat in another was split, exposing soft wood beneath, which was unhygienic. Records and visual checks indicated that routine maintenance checks and servicing of equipment had taken place. Infection control arrangements to prevent the spread of infection were in place in the laundry. Notices were posted in this area in relation to safe working practices with equipment, hazardous substances and to separate linen for appropriate laundering. It was noted that notices were posted in bedrooms to advise staff about the use of pressure relieving mattresses and similar. It was also noted that incontinence materials were on display in some bedrooms. The manager agreed that these practices were intrusive and compromised peoples’ privacy and dignity and stated that other arrangements would be introduced. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst it was evident that people in the home were being cared for by an experienced and committed team, gaps in training and failures to follow safe moving and handling guidelines had put those living in the home at risk of harm. EVIDENCE: Feedback about the conduct of staff from people using the service was positive. The questionnaire showed that eight of thirteen people were “Always” satisfied with the support they had received from staff and five were “Usually” satisfied. Comments verbal and written included, “Staff are very attentive, good humoured and prepared to listen”, “Very kind”. One person described their positive experience of living in the home and evidently enjoyed conversation and banter with staff. They explained how lonely they had felt prior to admission and now felt “so well”. The care was described as “wonderful”. Others were less satisfied with the availability of staff, two responded that staff were “Always” available, eight responded “Usually” two “Sometimes”. Comments included, “ Staff are very busy and cannot be prompt at all times”’ “When my relative is wet and needs changing they also need washing”, “ I Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 19 have been told I can do this for myself”. The complaint mentioned in section 4 referred to the lack of care for a person’s hygiene needs. Issues had been raised by the referral made under POVA mentioned in section 4 in relation to unsafe moving and handling practice. At the visit to the home the inspector observed a member of staff as they transferred a person from an armchair into a hoist and then transported them to a nearby toilet in this piece of equipment. The manual handing risk assessment for this person identified there must be two care staff for the transfer. It was unclear from the assessment whether the equipment was meant for transfer only or was to be used for transport. Information submitted by the provider in April 2007 showed that thirty-seven percent of the care team had achieved a National Vocational Qualification in care. Three personnel files were reviewed. They showed that satisfactory recruitment procedures had been followed that included checks on identity, previous employment and background checks as previously mentioned. Records included questions at interview and job offer letters detailing conditions of employment. The personnel files showed that staff had received basic training in statutory health and safety matters. One had been employed since 2005 and another since February 2006. Neither had undertaken training in dementia care, POVA or issues relevant to the care of frail older people such as diseases associated with old age, skin care, management of continence and similar. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had been without a manager until recently. Whilst it was evident that the acting manger had worked hard to carry on the home, there had been inevitable problems to ensure that the home was conduced at all times in the best interests of people using the service. EVIDENCE: The manager had been in post for approximately eight weeks as this visit to the home took place. Her application to be registered in her post had been received by the Commission and was being processed. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 21 Discussions with the manager and evidence of action she had taken since her appointment showed that she was aware of the responsibilities of a registered manager and the strategies required to manage the team to a professional standard. As evidenced previously in this report, issues for the manager’s attention, identified at this inspection, were gaps in essential training for staff, failure to carry out safe moving and handling practice, a failure to carry out a full pre-admission assessment of need, procedures to enable people to selfmedicate and the provision of meaningful Minutes seen showed that the acting manager had conducted regular meetings with staff and that the new manager had continued this process. Minutes were detailed and there was evidence to show that these were available to staff who had not attended. There had been fewer meetings with people living in the home. Minutes seen showed there had been two meetings in 2005, one in 2006 and two so far in 2007. Given the number of people living in the home who could actively contribute to such meetings it was suggested that more frequent meetings be scheduled. The home had carried out a formal consultation with people living in the home and /or their representatives in December 2006. The quality audit results showed that forty-two percent of respondents assessed the overall service as “Very good” and fifty-eight as “Quite good”. Monies held on behalf of people were in accordance with BUPA’s corporate systems. These systems paid monies received on behalf of people living in the home into private savings accounts and billed people or their representatives for purchases not included in costs for the accommodation, such as hairdressing and chiropody treatment. Small amounts of cash were held on site for those who wished to pay for these items directly. Records seen showed that proper accounts had been maintained of purchases made on behalf of people. The home acted as the appointee for two people. The records for one of these showed that there had been a large purchase made on their behalf of a specialised bed. Whilst this action had evidently been taken in the person’s best interests, there was insufficient evidence on file to show that the resident or their representative had agreed to the expenditure of a significant sum of money on this date. A document forwarded to the Commission after the inspection visit as evidence of consultation with this person’s family was dated 2004 whilst the date of the purchase had been made on 5th May 2006. There was no evidence of the representative having signed any such agreement, as would be best practice. There was also record on file dated after this purchase stating that this person’s family had requested that expenditures of significant amounts be discussed with them. Health and safety arrangements had been well managed. Information provided showed routine servicing and maintenance of equipment had been Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 22 carried out by qualified contractors. Members of staff had received training in safe working practices. Information provided showed that seventeen members of staff had received training in emergency first aid. Records seen indicated fire safety checks had been carried out as required on a routine basis and staff had received instruction and attended drills in fire safety practice. Records had been maintained of accidents and where people had fallen frequently they had been referred to their doctor. The manager stated that this action was scheduled to take place for someone who had been admitted recently and who had a history of falls prior to and since admission to the home. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 23 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 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 x x 3 Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1) Requirement The registered person must ensure that a detailed assessment of need is carried out before people are admitted to the home to ensure that it has the capability to meet all assessed needs. The registered person must ensure that assessments of need include the capacity to self medicate and that where it has been determined that people have this capability, they are supported to manage their medication. The home must introduce and implement a staff development plan that has been based on an analysis of individual need. Included in the plan must be: Manual handling update. Dementia/diseases/conditions associated with old age National Vocational Qualification in care Continence management Nutrition for older people. Skin care. The registered person must DS0000014901.V334807.R01.S.doc Timescale for action 30/06/07 2. OP9 12(1)(2) 13(2) 30/06/07 3. OP30 12(1)(a) 18(1)(c) 31/12/07 4. Ferndale OP35 12(2) 30/06/07 Page 25 Version 5.2 ensure that they have gained permission from people or their representative and properly evidenced the same before they spend large amounts of their personal money on their behalf. 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 OP12 Good Practice Recommendations Activities for stimulation and entertainment should suit peoples’ preferences should be provided more frequently. It is recommended that a survey be carried out to establish peoples’ wishes. Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Ferndale DS0000014901.V334807.R01.S.doc Version 5.2 Page 27 - 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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