Inspection on 28/02/07 for Ferndale Home For The Elderly

This inspection was carried out on 28th February 2007.

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

The inspector 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 16/03/06

Ferndale Home For The Elderly 26/08/05

Ferndale Home For The Elderly 08/03/05

Ferndale Home For The Elderly 22/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ferndale Home For The Elderly Britannia Road Morley Leeds LS27 0DW Lead Inspector Ann Stoner Key Unannounced Inspection 10:00 28th February 2007 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 Home For The Elderly DS0000001451.V311876.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 Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale Home For The Elderly Address Britannia Road Morley Leeds LS27 0DW 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) 0113 253 3196 0113 2380240 june.herron@btconnect.com Ferndale Residential Home Limited Mrs Betty Noble Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2006 Brief Description of the Service: Ferndale is a large detached property located in Morley, a suburb of Leeds, close to shops and other local facilities. It is registered to provide care, without nursing, for up to sixteen residents of both sexes, over the age of 65. There are three floors, but accommodation for residents is on the ground and first floor. The lower ground floor houses an office, staff room, storage room and the laundry. Accommodation for residents is in single and double rooms without en-suite facilities. A small number of bedrooms are available on the ground floor. A stair lift provides access to the first floor. However, residents have to climb three stairs to the corridor where bedrooms, toilets and the home’s two bathrooms are located. This accommodation may therefore not be suitable for residents with mobility problems. There are two comfortable lounges and dining room on the ground floor. The gardens are well maintained with outdoor seating areas for residents. There is a ramp leading to the front entrance. The home is on a main bus route from the city centre and there is a car park to the rear of the building. Fees that applied at the time of this inspection were stated in the preinspection questionnaire as ranging from £395 - £405. More up to date information may be obtained from the home. Copies of previous inspection reports are available in the home. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was unannounced and took place on the 16th March 2006. There have been no further visits until this unannounced key inspection, which took place between 10.00am and 6.00pm on the 28th February 2007. The purpose of this visit was to monitor standards of care in the home and to look at progress in meeting the requirements and recommendations made at the last visit. Before the inspection a pre-inspection questionnaire was sent out to the home, this provided some information for this report. The people who live in the home prefer the term ‘resident’ and this will be used throughout this report. Before the inspection survey cards were sent out to residents, relatives and health care professionals and there was a telephone conversation with two relatives. Five completed survey cards were received from residents, three from relatives and four from GPs. Comments from the survey cards and telephone conversations can be found throughout this report. During the inspection residents, visitors, staff on duty, the manager and the registered provider (owner) were spoken with. Records were looked at, a tour made of the building and staff watched working with residents. Feedback at the end of this inspection was given to the manager and the registered provider. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Because of the risks associated with the use of bed safety rails, the home must make sure that they are the best option for the resident before they are put into use. When in use, proper safety and maintenance checks must take place. All staff must know how to use, care and maintain any pressure relieving equipment in use in the home. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 7 To eliminate errors and reduce risks all staff must administer medication following guidelines issued by the Royal Pharmaceutical Society of Great Britain. Residents must not use any creams or ointments that have been prescribed for someone else. The home must not use any medication, cream or ointment beyond the expiry date. The home must look at ways of making bathrooms accessible to all residents. The home must introduce proper procedures to make sure that the risk of cross infection in the home is minimised. All opened packets of food must be tied or secured and labelled with the date on which the packet was first opened. Some minor amendments are needed to the way that the home records information on pre-admission assessments to make sure that the home is able to meet the person’s needs. To make sure that people at risk are properly identified the home must carry out nutritional and falls risk assessments when residents are admitted. Some minor amendments are needed to the home’s application forms and staff records to make sure job applicants are suitable and safe to work with older people. Where money is handed over on behalf of a resident for safekeeping, the home should obtain a signature from the person handing over the money. This reduces the risk of any future conflict. The manager should analyse all accidents on a monthly basis to identify any patterns and trends. A detailed list of the requirements and recommendations to address these issues can be found at the end of this report. 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 Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. Standard 6 does not apply to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives and friends are able to visit the home and have access to written information before making any decision about moving in. To make sure that the home can meet the person’s needs a pre-admission assessment is carried out, but the level of information recorded is variable depending on the person carrying out the assessment. This means that in some cases the information recorded is limited and staff do not have all the relevant information needed to make sure the person’s needs are met. EVIDENCE: All five residents who returned survey cards said that they had received a contract and they all indicated that they had enough information about the home before they moved in. During a telephone conversation before the Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 10 inspection visit, one relative confirmed that she had visited the home on behalf of her aunt, and had chosen it because of the ‘family atmosphere’. She confirmed that she had access to written information about the home before her aunt was admitted. In returned survey cards one resident said that she had visited the home as a church member, so knew she would like living there. Another said that his daughter had helped him choose the home, and that he was ‘very happy here’. Another resident said that her social worker and her brother had helped her choose the home, and that she liked it because, ‘it was just like home.’ Three care plans were sampled and in all cases the home had carried out a pre-admission assessment to make sure that the person’s needs could be met. Some assessments were more detailed than others, and there was no information about who was involved in the assessment process and who had supplied the information. The registered provider said that prospective residents are invited to visit the home and stay for a meal before making any decision about moving in. This information is recorded in the home’s diary and on an Enquiries for Vacancies form. It is recommended that this information be transferred to the pre-admission assessment form. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall care plans give staff enough information on how to meet the resident’s individual needs, but the lack of nutritional and falls risk assessments, means that some residents at risk may not be identified. The lack of safety and maintenance checks on bed safety rails puts residents at risk. The practice of residents using medication that has been prescribed for someone else, and that is out of date, poses a serious risk to residents. EVIDENCE: The care plans of three residents were sampled. Although additional information was needed, particularly in the case of those people who have diabetes, the care plans were person centred and identified the choices, likes and dislikes of residents. There was also evidence that care plans are updated Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 12 as and when needs change. Care plans are reviewed monthly. There were no nutritional assessments or falls risk assessments in place to identify those people at risk. There was evidence in all of the records sampled that residents have access and visits from health care professionals such as an optician, chiropodist, district nurses and GPs. Four GPs who returned survey cards all indicated that the home communicates clearly and works in partnership with them. All five residents who returned survey cards indicated that they receive medical support when needed. Bed safety rails were being used for one resident. There was no assessment in this person’s care plan showing that bed rails were the most suitable option considering all the risks associated with their use. The manager said that the district nurse had carried out an assessment, but there was no evidence of this in the home. The position of the bed rails in relation to the position of the person in the bed created a risk of entrapment. The manager made arrangements for these to be moved immediately. The manager was unaware of the need for safety or maintenance checks to be made when bed rails were in use. A copy of the ‘Safe Use of Bed Rails’ was left at the home. This resident also had a pressure mattress. This was set at the wrong setting for the person’s weight. The manager said that she was unaware of this. She was advised to contact the district nurse the following day. The home uses a blister pack system of medication, but because of the way that the home administers medication from the blister packs there is the potential for medication errors. Instead of administering medication to residents on an individual basis, medicine pots are lined up on a tray labelled with each person’s name and medication from the blister pack is dispensed into the medicine pots. To administer medication staff carry the tray of medicine pots containing all of the medication to be administered at that time. This practice is unsafe. There was a bottle of Simple Linctus in the medication trolley but the pharmacy dispensing label had been torn off, therefore it was impossible to determine which resident had been prescribed this medication. The registered provider said that she thought the medicine belonged to a member of staff. There was a small supply of homely remedies in the medicine trolley that included, Witch Hazel, Zoviraz, Olbas Oil and Oruvail Gel. There were no instructions for staff on how and when they should use these remedies, and there was no GP agreement for their use. There were a number of creams in use in resident’s bedrooms, some of which had the pharmacy label removed and the resident’s name written in black felt tipped pen. None of these creams had been prescribed for the resident who was using the cream and they did not appear on the person’s medication administration record (MAR). One person was using Betnovate cream; the pharmacy label showed that the cream had been prescribed for a deceased resident. The cream, which was still in Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 13 use, was dispensed in July 2003 and expired in October 2005. Another resident was using cream that expired in December 2005; the pharmacy label was undistinguishable. Handwritten entries on MARs are not checked and countersigned by a second person. Throughout the day staff were seen respecting the privacy and dignity of residents and through discussions with staff it was clear that they were aware of the importance of residents being in control of their lives and maintaining as much independence as possible. A number of requirements and recommendations have been made. The manager and registered provider were unaware of the issues above and agreed at the feedback session to address these immediately. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 14 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): 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. Residents have control and choice in their lives, they have a healthy diet and their social and recreational needs are met. Visitors are made welcome. EVIDENCE: Resident’s preferred times for getting up in the morning, going to bed at night and likes and dislikes in relation to clothes and food are all specified in their plan of care. Through discussions with staff it was clear that they understand the importance of respecting resident’s individual choices. All five residents who returned survey cards said that there are activities arranged by the home that they can take part in. One person said, “I like the Vicar to come, I can have a laugh with him.” Another said, “I like the games on Friday the young man makes me laugh.” During the inspection visit staff were seen providing activities to residents that were identified in the person’s plan of care. In a returned survey card one resident said, “One staff member helps me to write to my daughter every week, which I’m pleased about as I am not able to see to write very well.” The manager has been on a training Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 15 course and as a result is introducing memory boards for individual residents as a means of reminiscing. One almost completed had lots of photographs of the resident’s family and postcards of Morley some dating back to pre-war days. Immediately it was shown to the person it initiated a lengthy conversation. This is good practice. During the inspection visit one resident was entertaining two visitors in her bedroom. Staff had prepared a tray of tea and biscuits for them. The visitors said that this was standard practice, and that they are always made to feel welcome. This view was confirmed during telephone conversations before the inspection with relatives. All residents who returned survey cards said that they always liked the meals, and comments included, “Excellent,” “I always look forward to my meals and enjoy them.” Residents appeared to enjoy the lunchtime meal on the day of this visit, which was roast chicken with sage and onion stuffing, potatoes, carrots, cabbage and gravy followed by a choice of puddings and tea or coffee. Staff said that the teatime meal is usually sandwiches but residents can choose from a range of alternative options. It is recommended that residents be reminded of these options on a daily basis and encouraged to choose their preferred option. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 16 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): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and visitors know how to make a complaint. Minor complaints have not always been recorded so there is no way of accurately identifying how many complaints have been made or how they have been dealt with. Staff have a good understanding of adult abuse and methods of reporting. EVIDENCE: The pre-inspection questionnaire shows that there have been no complaints in the last twelve months. However, it became clear during a discussion with the manager and the registered provider that minor complaints are not recorded. The registered provider agreed to rectify this immediately. The home has a complaints policy, which is clear and concise. All five residents who returned survey cards said they knew who to speak to if they were not happy and they all knew how to make a complaint. During telephone conversations before the inspection visit, relatives said that they would have no hesitation in making a complaint if necessary. The manager has completed adult protection training and is now cascading this training to other staff in the home. Care staff understood the different types of abuse and knew when and how to report any suspicions of abuse. The home Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 17 did not have a copy of the Multi-Agency Adult Protection Procedures. A recommendation has been made. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is adequately maintained. Access to most bedrooms and all bathrooms is restricted for those residents who cannot climb stairs. Some practices in the home increase the risk of cross infection. EVIDENCE: Some bedrooms need updating, but the home’s annual development plan for 2007/8 shows that some bedrooms are to be decorated, some wardrobes are to be varnished, some new vanity units are to be fitted and remaining radiators that are unguarded are to fitted with guards. Development work during 2006/7 has included new flooring in toilets, new commodes, new headboards and some new window frames. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 19 The home has two bathrooms, one of which may be converted to a shower room to offer residents more choice. There is a stair lift to the first floor, but residents still have to climb three stairs to reach all of the bedrooms on this floor and the home’s two bathrooms. There are currently three residents with bedrooms on the ground floor, that have bed baths because they cannot access the bathrooms. The registered provider said that she has considered fitting a second stair lift to the three stairs but feels that the staircase is too narrow. This could affect any new admissions to the home, as well as current residents as and when their needs and mobility deteriorate. The risk of cross infection in the home is increased because of the following practices: • • • • there are no disposable towels other than those in the kitchen and staff toilet soiled linen is hand sluiced and the home does not use water-soluble bags when laundering soiled linen staff do not wear disposable aprons when coming into contact with clinical waste or bodily fluids, particularly when assisting residents to the toilet There is no liquid soap, disposable towels or clinical waste bin in the laundry. The manager and the registered provider were unaware of the above issues and agreed to address them immediately. All parts of the home were clean and tidy with no offensive smells. A cleaner described good routines and said that she had completed a National Vocational Qualification (NVQ). Requirements have been made. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 20 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): 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. Staffing levels meet the needs of residents. There is plenty of training available to staff, but the management team do not always make sure that theory is transferred into practice. Proper recruitment checks are made to make sure that people are safe and suitable to work with older people. EVIDENCE: All five residents who returned survey cards said that there are always staff available when needed. All four GPs who returned survey cards said there is always a senior member of staff to confer with. In a returned survey card one relative said, “There is always staff around to answer questions or concerns.” The rota shows that the cook goes home at 1.30pm, which means that care staff have to prepare, serve and clear away tea. On occasions staff said that there are only two care staff on duty. The manager said that staffing levels have been increased to address this. The pre-inspection questionnaire shows that 65 of staff have an NVQ (National Vocational Qualification) and almost all of the staff team hold a current first aid certificate. Training undertaken during the last twelve months Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 21 includes, fire training, health and safety in the workplace, caring for confusion and protection of vulnerable adults. Staff have also completed training on infection control and safe administration of medicines, but as previously stated earlier in this report, practices in the home in both of these areas create potential risks to residents. The management team must make sure that they are familiar with the content of courses undertaken by staff and that they make sure theory is transferred into day-to-day working practices. New staff complete an induction training package that is linked to the Skills for Care induction standards. The recruitment records for three members of staff were sampled. In all cases there was a completed application form, 2 written references, interview records and job descriptions. Application forms do not ask for a full employment history since leaving school. The CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adults) disclosures were obtained before the offer of employment was made. The home receives information about POVA checks by telephone, which means that there is no evidence in the home that the check has been successful. The registered provider agreed to look into this. Recommendations have been made. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 22 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): 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 health, safety and welfare of residents, particularly in relation to medication, infection control and maintenance of bed safety rails, is not always promoted. EVIDENCE: The manager has many years of experience in the care of older people and holds the Registered Manager’s Award. She is well thought of by staff, residents and relatives. Comments from relatives included, “The manager and staff are excellent, caring, kind and professional.” During a telephone conversation with a relative before this inspection visit he said, “The manager has always been more than helpful.” Despite these positive comments, several Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 23 areas of concern have been identified in this report. It is the manager’s responsibility to keep up to date with current practices and to make sure that these are implemented in the home. The home sends out annual quality assurance questionnaires to relatives and residents and the information from these is used to improve the service. The registered provider said that she is thinking about changing the format of the questionnaires so that more probing questions are asked. The registered provider said that she has not completed any Regulation 26 visits because she works in the home most days. She is aware of the need to carry out these visits. Records of money held on behalf of residents were accurate and up to date. The home issues a receipt when money is handed over on behalf of a resident, but the signature of the person handing over the money is not obtained. The pre-inspection questionnaire shows that maintenance and servicing of equipment takes place as necessary. A selection of COSHH (Control of Substances Hazardous to Health) risk assessments was sent to the CSCI before this inspection visit. These were all in order. As identified earlier in this report poor practices in relation to the administration of medication, lack of maintenance checks on bed safety rails and poor infection control measures all potentially affect the health and safety of residents. In addition there were opened packets of frozen vegetables, sausages and chips in the kitchen freezer. These were not secured or tied and there was no record of the date on which the packet was opened. There were several open packets of cereal on a shelf in the kitchen. These should be stored in a container. Fire drills are carried out every 6 months, and fire bells are tested weekly. The manager is in the process of updating the home’s fire risk assessment. Accidents are not analysed on a monthly basis to identify any trends or patterns. Where an accident is not witnessed by staff there is no record kept of when the person was last seen or by whom. Requirements and recommendations have been made. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 13 Requirement To make sure that bed safety rails are safe for the person using them, the home must complete a bed safety rail assessment before they are put into use. This assessment must show that all other options have been considered. This assessment must be kept under review. Timescale for action 01/05/07 2 OP8 13 3 OP9 13 The home must introduce maintenance and safety checks of bed rails. All staff must be familiar with the hazards associated with the use of bed rails and know how to carry out safety checks. Staff must know how to use, 01/05/07 care and maintain pressure relieving equipment in use in the home. Staff must administer medication 01/05/07 safely and follow guidelines from The Royal Pharmaceutical Society of Great Britain. Residents must only use medication, creams and ointments that have been Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 26 prescribed for them and is recorded on their individual medication administration record. Medication, creams and ointments must not be used beyond the expiry date. The home must consider ways to make bathrooms accessible to all residents. To reduce the risk of cross infection the home must: provide liquid soap and disposable towels in all bedrooms, toilets, bathrooms and the laundry room • provide water-soluble bags for laundering soiled linen. • provide disposable aprons for staff, which must be worn when coming into contact with clinical waste. • provide a clinical waste bin in the laundry. The registered provider must complete Regulation 26 visits. Food that has been opened, must be tied or secured and labelled with the date on which it was first opened. • 4 5 OP19 OP26 23 (a) (j) 13 31/08/07 01/05/07 6 7 OP33 OP38 26 13 31/03/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The information recorded on the pre-admission assessment should be in sufficient detail so that it forms the basis of the care plan. This would make sure that the DS0000001451.V311876.R01.S.doc Version 5.2 Page 27 Ferndale Home For The Elderly home is able to meet the person’s needs. The pre-admission assessment should identify those people who were involved in the assessment, and who supplied the information. A record should be made on the pre-admission assessment of any introductory visits and the outcome of the visit. To make sure that people at risk are correctly identified nutritional and falls risk assessments should be carried out during the admission process and updated as and when necessary. The monthly review of the care plan should show how the plan is effective and is still meeting people’s needs. To reduce the risk of errors handwritten entries made on medication administration records should be checked and countersigned by a second person. The homely remedy policy should identify the homely remedies used by the home, the circumstances of their use, the maximum dose in 24 hours, and how long the remedy should be used before GP contact is made. The resident’s GP should sign a consent form agreeing to the use of homely remedies. Residents should be reminded of the teatime options on a daily basis and encouraged to choose their preferred option. The home should obtain a copy of the Multi-Agency Adult Protection Procedures. All staff should be made aware of these procedures so that they know exactly what to do in the event of adult abuse. To make sure job applicants are suitable to work with older people, the job application form must be amended to include a full employment history since leaving school. The home must provide some evidence in the staff file that the POVA (Protection of Vulnerable Adults) check has been successfully carried out. Where money is handed over to the home, on behalf of a resident, a signature should be obtained from the person handing over the money. If an accident is not witnessed by a member of staff, a record should be kept of when the resident was last seen and by whom. The manager should analyse all accidents on a monthly basis to identify any patterns or trends. Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 28 2 OP7 3 4 OP7 OP9 5 6 OP15 OP18 7 OP29 8 9 OP35 OP38 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ferndale Home For The Elderly DS0000001451.V311876.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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