Inspection on 29/11/05 for Ferndale

This inspection was carried out on 29th November 2005.

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 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 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 20/07/06

Ferndale 21/02/06

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 John Hurley Unannounced Inspection 29 November 2005 9.30 Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 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.V260438.R01.S.doc Version 5.0 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.V260438.R01.S.doc Version 5.0 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.V260438.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 2 PERSONS IN CATEGORIES LD AND MD Date of last inspection 18th February 2005 Brief Description of the Service: Ferndale is a small home located in a residential area of Shepton Mallet. The home provides accommodation to two service users who require a high level of care and support. Each service user has their own bedroom, living room and bathing facilities. There is a garden to the rear of the property, which is accessible to both service users. A behavioural management approach has been tailored to meet the specific needs of the service users. A small staff team supports the service users within a ‘low arousal’ environment. The home has access to additional support from multi-disciplinary professionals. Ferndale is registered with the Commission for Social Care Inspection to provide care for two service users who have a learning disability. The Registered Manager is Melvyn Phillips. The Registered Provider is Orchard Vale Trust, a non-profit making company and a registered charity. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was completed on 29/11/2005. Whilst this inspection would normally have been unannounced due to the dependency levels of the two service users a unannounced inspection is not currently possible. However the service was only given two days notice of the intended inspection. The two service users were at home during the inspection supported initially by two staff. What the service does well: 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.V260438.R01.S.doc Version 5.0 Page 6 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.V260438.R01.S.doc Version 5.0 Page 7 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 homes documentation and information relating to the current service users indicates that if a place became available, staff have the necessary skills and professionalism to be able to meet the National Minimum Standards required. EVIDENCE: Through discussions with the staff and by assessment of previous inspection reports the inspector established that standards 1,4 and 5 have not been assessed since the inspection on the 10 August 2004 where the inspector considered these standards to be fully met, this is still considered to be the case. The deputy manager informed the inspector that there have been no new admissions and none are anticipated in the foreseeable future. Through discussion with the deputy manager the inspector established that there are systems in place to ensure that any new admissions would be based on a sound and comprehensive assessment. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 8 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): 6,7,9 The standard of service user files is good and reflects the goals and aspirations of the individual. Staff consult with service users about matters that effect them. EVIDENCE: The service users files appeared to be comprehensive and contained highly developed care plans. The staff have translated their knowledge of the individual service user into documents that explain behaviour, how this behaviour may be triggered and strategies for avoiding unwanted behaviour where possible. The reviews that are carried out evidence that the staff works well with other agencies and people important to the service user in providing a need’s led, person centred service. The inspector spoke with and observed the service users go about their own daily routines. It was reasonably clear that the individuals were making choices where possible. The staff informed the inspector that the service user is encouraged to take responsibility for their own environment (with support) and thus every day cleaning is generally the responsibility of the individual. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 9 Through discussion with the staff and by sampling some of the service user documentation it is clear that any restrictions on the individuals lifestyle is based on a comprehensive risk assessment. There is also sufficient evidence to suggest that the service user and their advocates agree with these restrictions. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 10 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): 11,12,13,14,17 The routines of the home are unhurried and appear to suit the individuals needs and aspirations. EVIDENCE: It is recorded that the service users attend a range of activities and outings including: art therapy, music therapy, pottery, cinema, swimming, visits to the park and eating out. Service users are also provided with a holiday each year. Records inform that staff support service users in accessing the local community. Shopping trips, pub lunches and social activities occur each week. Staff at the home supported by the service users prepares the meals. A healthy diet is promoted. Service users were observed as being engaged in the choice and preparation of meals. Service users are provided with regular opportunities to eat out. Positive feedback was received from the service users regarding the meals provided. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 11 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): 19,20 The records observed demonstrate that the service users health care and emotional needs are acknowledged and acted upon in a proactive way. EVIDENCE: The records observed evidence that service users have regular health care checks from the GP. They also see other professionals including a psychiatrist, psychologist if required. The inspector viewed the relationship between the service users present at the time of the inspection as both empathetic and professional. It was also observed that staff use positive encouragement to gently assist the individual when making choices. Due to the individual service user abilities at present no one self medicates. Appropriate policies and procedures are in place in relation to assisting with medication. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 12 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 Opportunities to raise issues and comment on the service are good. Some further thought with regards to vulnerable adult and complaints policies would be helpful. EVIDENCE: No complaints have been made to either the home or directly to the regulator, similarly no vulnerable adults issues have been raised. Feedback regarding the service provided is sought on a regular basis from families and during reviews. The inspector viewed the new policies that are being developed with regards to complaints and vulnerable adults. The organisation needs to ensure that the regulators name and contact details are included in the complaints procedure, vulnerable adults policy must also reflect the current protocols of the local authority. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 13 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): 24,25,27,30 The home is well maintained and currently meets the needs of the service users. EVIDENCE: The inspector toured the home and found that it was clean and maintained in good decorative order. Service users have separate living rooms, bathrooms and bedrooms and share the communal kitchen. The inspector considered that the service user rooms have been decorated and furnished to a high standard. They also noted that appropriate adaptations have been provided to meet service users individual needs. It is evident that staff have sought to ensure that rooms remain homely, whilst also promoting the health and safety of service users. Some of the unwanted behaviour displayed by the service users manifests itself in the destruction of personal belongings and space. At the time of the inspection one individual’s living room was currently being refitted after such an episode. The staff informed the inspector that the service user was consulted about and made real choices about how this refit should be done. The service user confirmed this. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 14 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): 31,32,33,35,36 The staff of Ferndale are appropriately trained to meet the needs of service users, benefiting from a inclusive decision making management structure. EVIDENCE: A small stable staff team provide a consistent approach to the care of the two service users. The staff informed the inspector that the home is managed in an open and reflective manner. Staff further confirmed that they are fully consulted about the models of care employed within the home and understand the needs for clear and consistent boundaries for the service user. Staff training was discussed during the inspection. The management team at home generally ensure that staff are provided with appropriate training program to meet the specific needs of the service users that they care for. The requirement to ensure that staff have up to date Fire training had yet to be attended too. Through discussion with the deputy manager it was clear there had been a misunderstanding with regards to the expectations of this requirement. Following an explanation of this requirement the deputy manager agreed that staff will receive appropriate fire training. Staff confirmed that they receive regular formal supervision the records sampled confirmed this. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 15 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): 37,38,40,43 The home is well managed and provides needs lead service. The models of care that are followed within the home require clear and accountable leadership, this appears to be consistently achieved. The management acknowledge that fire training is required. EVIDENCE: The inspector viewed a number of key documents during the inspection ranging from care plans to staffing records, these documents were well laid out and found to be in good order. The staff the inspector spoke with said that the manager was approachable and fair, often working with them and the service users. They further informed the inspector that people important to the service user are kept fully informed of developments of the service and are included where appropriate. The requirement to ensure that staff have up to date Fire training had yet to be attended too. Through discussion with the deputy manager it was clear Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 16 there had been a misunderstanding with regards to the expectations of this requirement. Following an explanation of this requirement the deputy manager agreed that staff will receive appropriate fire training. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x N/A x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ferndale Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 2 3 DS0000016293.V260438.R01.S.doc Version 5.0 Page 18 Yes 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 YA35 Regulation 23(40)(d) Requirement The registered manager must ensure that all staff receives regular updates in fire safety training. Timescale for action 31/01/06 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 2 Refer to Standard YA22 YA23 Good Practice Recommendations The organisation needs to ensure that the newly developed complaint policy contains the contact details of the regulator. That the organisation considers how its vulnerable adult policy fits with the local authorities policies regarding this matter. Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ferndale DS0000016293.V260438.R01.S.doc Version 5.0 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!