Inspection on 26/08/05 for Ferndale Home For The Elderly

This inspection was carried out on 26th August 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 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 Home For The Elderly 05/03/08

Ferndale Home For The Elderly 28/02/07

Ferndale Home For The Elderly 16/03/06

Ferndale Home For The Elderly 08/03/05

Ferndale Home For The Elderly 22/06/04

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Hawkhills

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ferndale Britannia Road Morley Leeds LS27 0DW Lead Inspector Steve Marsh Unannounced 26 August 2005 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 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 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ferndale Address Britannia Road Morley Leeds LS27 4DW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2533196 0113 2380240 Ferndale Residential Home Ltd Mrs Betty Noble Care Home Only 16 Category(ies) of Old Age (16) registration, with number of places Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 08/09/05 Brief Description of the Service: Ferndale is a large detached property located in the Morley area of Leeds, close to the shops and other facilities. The home is on a main bus route from the city centre and there is a car park to the rear of the building. The home is registered to care for sixteen service users in both single and double bedrooms (without en-suite facilities), situated on both the ground and first floor of the building. There is a stair lift available to bedrooms/facilities on the first floor of the building, however service users are still required to climb three steps to reach this area. This accommodation may therefore not be suitable for service users with mobility problems. There is however ramped access to the main door of the property, and all the communal areas used by the servic users including the lounges and dining room are situated on the ground floor. Communal toilets are conveniently located throughout the building and there are two communal bathrooms (one assisted) located on the first floor. Externally the building appears well maintained and the grounds are attractive, with sufficient space for the sercvice users to sit out during the summer months . Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection visit for the year 2005/06, and was carried out by one Inspector over a period of about eight hours. The last inspection of this service was in March 2005 and the main purpose of this visit was to assess the progress made in meeting the requirements and recommendations highlighted in the inspection report. The methodology used in this inspection included the examination of records, observation of work practices, discussion with the service users and staff and a tour of the building. Comment cards were provided for the service users and/or their relatives to enable them to share their views of the service with the Commission. Comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondent. The Inspector has visited Ferndale Care Home over a period of eighteen months and therefore drew on information already known about the home when completing this report. The Inspector would like to take the opportunity to thank the manager, members of the staff team, visitors and service users who participated in the inspection process for the co-operation. Feedback was given to Mrs Betty Noble (registered manager) at the end of the visit. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home provides a safe and comfortable environment for the service users and the staff team are approachable and appear to have a genuine understanding of their needs. There is a very stable staff team at the home, which ensures that the service users receive continuity of care. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 6 The admission procedure for the home is thorough and the manager will not admit service users unless she feels that the staff team can provide the level of care/support they require. The service users healthcare needs are met, and any problems are identified at an early stage and a referral made to the appropriate professional agency i.e. general practitioner, district nursing service. Members of staff encourage the service users to make as many decisions as possible in relation to their daily lives and activities/outings are organised in line with their wishes. There is a commitment to staff training both to meet the needs of the service users and for personal development, and members of staff appear aware of their roles and responsibilities. The home is well managed and the views and opinions of the service users are actively sought to ensure that they are receiving the standard/level of care and/or support they require. What has improved since the last inspection? What they could do better: Members of the senior staff team need to be more vigilant when recording the stock control figures for prn (as and when required) medication to ensure mistakes are not made. Some areas of the home still require refurbishing as part of the homes ongoing programme of refurbishment and renewal. Access to the first floor of the building would be greatly improved by the installation of a second stair lift so that service users do not have to climb stairs to reach the accommodation and/or bathroom facilities. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,5 Service users and/or their relatives are provided with sufficient information to enable them to make informed decisions about the home. The admission procedure is good and includes pre-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: The records reviewed showed that pre-admission assessment visits are carried out to see prospective service users either in their own home or temporary place of residence. The manager confirmed that the service user, their relative and/or other professionals involved in their care contribute to the assessment process, and the needs identified during this visit are reflected in the initial care plan. Unplanned admissions are avoided if at all possible although the home will respond to crisis situations and take emergency admissions providing the manager is sure that the staff team can meet their needs. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 10 In addition to the pre-admission assessment visit service users and/or their relatives are also invited to visit the home prior to admission to view the accommodation, meet the other service users and staff and stay for a meal if they wish to do so. Service users are also able to move into the home for a trial period to enable them and/or their relative to make an informed decision about their long-term future. Service users/relatives spoken to, confirmed that the staff had been very helpful when they had initially visited the home and had provided general information about the care/service provided and answered any question asked. All service users are provided with a contract (terms and conditions of occupancy) on admission to the home as required. There appears to be the experience/skill mix within the staff team to meet the needs of the residents in their care and training continues to be actively encouraged by the manager. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Records and reports about the service users welfare show that their healthcare needs are met and any problems are identified at an early stage and referred to the appropriate professional. However, the manager must ensure that senior members of staff are more vigilant when completing the stock control records for prn (as and when required) medication to ensure mistakes do not occur. EVIDENCE: Care plans have been completed for all service users and there is sufficient evidence in the documentation to show that they and/or their relatives are involved in the care planning process. The manager confirmed that the care plans are reviewed on at least a monthly basis, or sooner if the needs of individual service users change significantly. In addition to the care plans risk assessments have also been completed for individual service users where specific areas of concerns have been identified. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 12 All service users are registered with a general practitioner and have access to the full range of NHS services. The home has established good working relationships with other healthcare professionals i.e. general practitioner, district nurses etc and advice is always sought if the staff have any concerns about the general health of a service user. Service users spoken to confirmed this, and said that prompt medical attention was provided if they felt unwell, which they found reassuring, and medical examinations were always carried out in the privacy of their own room. It was apparent through discussion with the service users that members of staff treat them with respect and maintain their dignity when assisting with personal care tasks. Members of staff were also observed to knock on bedroom doors prior to entering the service users bedrooms, and refer to them by their preferred term of address. On reviewing the medication system in place at least two discrepancies were noted in the stock control system for prn (as and when required) medication and therefore this matter must be addressed. The manager confirmed that members of the senior staff team are currently completing a course on the safe handling of medication, which they are finding very informative. At the present time no service users administer their own medication but the manager confirmed that new admissions to the home would be encouraged to do so if they had the capability. The staff team continue to monitor the general health of service users taking long-term medication, and would seek professional advice if they had any concerns. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The home offers a range of social and leisure activities and the service users are encouraged to make informed decisions about their lifestyle. Meals appear nourishing and take into account the service users likes and dislikes. EVIDENCE: The daily routines of the home appear flexible and are based around the needs of the service users. The home does not employ an activities co-ordinator therefore it is the responsibility of the care staff to organise activities, outings and entertainment for the service users. The interests and hobbies of individual service users are recorded in their care plan, and the manager confirmed that wherever possible they are encouraged to continue with their chosen hobbies/interests for as long as it is practical for them to do so. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 14 In addition to the in-house activities organised by the care staff, music and light exercise classes are held for the service users on a regular basis, which they confirmed they look forward to and enjoy. Outing to the theatre etc are also arranged in line with the wishes of the service users and the hairdresser visit the home on a weekly basis. The manager confirmed that religious leaders from local churches also visit the home and arrangement would be made for service users to attend church etc if they wish to do so. Service users spoken to said that they were happy with the level of activities organised for them, and liked the fact that they were able to decide whether or not they wanted to join in activities or plan their own daily routine. Some service users also said that they preferred to simply spend their day watching television, listening to music or reading the daily newspapers provided for them. Service users confirmed that they were able to see visitors in the privacy of their own room, and that relatives and friends where made to feel welcome when they visited the home and offered light refreshment. The meals at the home where described by the service users as very good, and they confirmed that they were always offered an alternative if they did not like what was on the menu. Service users requiring assistance/prompting with their meals receive discreet support and assistance to ensure that they eat a nutritious and balanced diet. Hot and cold drinks are freely available to the service users both day and night. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Robust complaint and adult protection procedures ensure that the service users are listened to, and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and the residents spoken to said that they knew what to do and who to approach if they were unhappy with the standard of care/service they receive. The manager confirmed that no complaints have been received since the last inspection visit. Policies and procedures are in place at the home in relation to adult protection and as recommended in the last inspection report the manager has recently attended an appropriate training course, and is presently in the process of making the information available to all members of the staff team. Members of staff spoken to confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to safeguard the service users from any form of abuse. The manager is also aware of the Protection Of Vulnerable Adults register and the recruitment and selection procedure for the home has been amended taking this into account. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 16 A policy document is available in relation to handling the service users financial affairs, which does not allow members of staff to be involved in the making of, and/or benefiting from their wills. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24,26 The home provides a pleasant, comfortable and safe environment for the service users, however the registered provider/manager are aware that some areas of the building still require refurbishing. EVIDENCE: Internally the home is generally well maintained although some areas of the home would benefit from decorating as part of the homes ongoing programme of refurbishment and renewal. All the communal areas used by the service users consisting of two lounges and a dining room are situated on the ground floor of the home, close to communal toilet facilities. The manager confirmed that one lounge and the dining room are to be decorated in the near future, and the lighting in dining room is to be changed from the present fluorescent strip lighting, to lighting, which is more domestic in character. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 18 It was however noted that the carpet in the dining room would also benefit from replacing and this should be renewed when the room is decorated. Bedrooms are located on both floors of the home and consist of both single and double rooms. There is a stair lift to the bedrooms on the first floor of the building, although as previously mentioned in this report service users are still required to climb three steps to reach the accommodation. Both bathrooms are also situated on the first floor of the building and therefore the home may not be suitable for service users with mobility problems. The provider is however considering installing a second stair lift, which will make access easier. Service users spoken to said that they were happy with the standard of accommodation, and were pleased that they had been able to furnish their rooms with personal possessions. Handrails and grab rails are available throughout the home as required and the emergency call system covers all areas of the home. On the day of inspection the home was clean and tidy and free from offensive odours. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 The home has a stable staff team, which ensures that the service users receive continuity of care and their needs are met. Members of staff are encouraged by the manager to study for a professional qualification (NVQ), and additional training both to meet the needs of the service users and for personal development is provided. EVIDENCE: A rota for the week of inspection was taken, which showed that sufficient numbers of staff are employed on both day and night duty to meet the needs of the service users. The home has a very stable staff team and the manager confirmed that no new members of staff have been employed since the last inspection visit. All members of staff providing personal care are over eighteen years of age and all senior members of staff are over twenty-one years of age in line with the National Minimum Standards. The home employs sufficient catering and cleaning staff to ensure the premises are kept clean and the dietary needs of the service users are fully met. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 20 To ensure continuity of care the home does not employ agency staff and any shortfall in staffing hours due to holidays or sickness is covered by members of the staff team working additional hours. All members of staff are encouraged to gain a professional qualification and the manager confirmed that with the exception of two, all members of staff have achieved a National Vocational Qualification (NVQ) at level two. Members of staff spoken to confirmed that training was actively encouraged at the home and requests to attend training courses were always supported by the manager. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,38 The home is well run and the manager provides good leadership to the staff team, and ensures that the service users are protected and their needs are met in line with their care `plan. The views and opinion of the service users and/or their relatives are actively sought and valued. Policies and procedures are in place to ensure the health and safety of the service users, visitors and members of the staff team. EVIDENCE: Mrs Betty Noble has been the registered manager of the home for a number of years, and has recently achieved the Registered Managers Award. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 22 Mrs Noble appears to communicate a clear sense of direction and leadership to the staff team, and staff confirmed that she has an open and approachable management style. The manager ensures clear channels of communication with the staff by holding regular staff meetings, and formal one-to-one supervision with individual members of staff takes place at least every two months in line with the National Minimum Standards. In addition the manager also works within the home on a daily basis and is therefore available to deal with any quires/concerns raised by the staff or service users. The manager confirmed that quality assurance systems are in place at the home, including the constant self-monitoring of management arrangements and care practices. In addition quality assurance questionnaires have also recently been sent out to service users, relatives and other professionals accessing the service i.e. district nurses, pharmacist etc and the provider is presently summarising the responses. The manager was reminded that when the results of the survey are known they must be made available to all interested parties including the Commission. The home holds money in safe keeping for a number of service users and on reviewing the system in place no concerns were raised. Only the registered provider and manager handle money held in safekeeping and transaction sheets are available showing income, expenditure and a balance. Policies and procedures are in place to ensure the health and safety of the service users, visitors and staff and they are reviewed on a regular basis to ensure they comply with present legislation. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 3 3 x 3 3 x 3 Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 24 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 9 Regulation 13(2) Requirement The registered manager must ensure that accurate stock control records are maintained for prn (as and when required) medication. Timescale for action 30/09/05 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 20 Good Practice Recommendations The carpet in the dining room should be replaced when the the room is decorated. Ferndale 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 20050826 Ferndale UN Stage 4 S1451 V181408 J521.doc Version 1.40 Page 26 - 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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