Inspection on 05/03/08 for Ferndale Home For The Elderly

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ferndale Home For The Elderly 28/02/07

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

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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 Hebrew Rawlins Key Unannounced Inspection 09:00 5th March 2008 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.V360459.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.V360459.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 ferndale.rh@talktalk 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.V360459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2007 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 people over the age of 65. There are three floors but accommodation for people is on the ground and first floor. The lower ground floor houses an office, staff room, storage room and the laundry. Accommodation for people 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, people have to climb a flight of three stairs to the corridor where bedrooms, toilets and the home’s two bathrooms are located. This accommodation may therefore not be suitable for people with mobility problems. There are two comfortable lounges and a dining room on the ground floor. The gardens are well maintained with outdoor seating areas for people. 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. The current fees range from £408.00 to £418.00 per week with additional charges for hairdressing and chiropody. Newspapers and toiletries are included in the fees charged. The manager provided this information to the Commission for Social Care Inspection on 5 March 2008. Copies of previous inspection reports are available in the home. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. Information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and carried out by one inspector who was at the home from 9.15 hours until 16.20 hours on 5 March 2008. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and wellbeing of the people who use the service and in accordance with requirements. Before the inspection, accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. During the visit, a number of documents were looked at and areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information about the home. Survey forms were sent out to the people who use the service, relatives, carers, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. Feedback at the end of this inspection was given to the manager. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager makes sure bed safety rails are safe for the person using them. The home now completes a bed safety rail assessment before they are put into use. This assessment shows all other options have been considered to bed safety rails and is kept under review. The home has introduced maintenance and safety checks of bed rails. Staff are now familiar with the hazards associated with the use of bed rails and know how to carry out safety checks, making sure bed safety rails are safe for the people in the home. The Manager makes sure people only use medication, creams and ointments that have been prescribed for them and this is recorded on their individual medication administration record. Medication, creams and ointments are not used beyond the expiry date. The home manages infection control well, making sure liquid soap and disposable towels are available in all bedrooms, toilets, bathrooms and the laundry room. Also water-soluble bags for laundering soiled linen and disposable aprons for staff are provided, which are worn when coming into contact with clinical waste. Food that has been opened is tied or secured and labelled with the date on which it was first opened making it safer for use. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ferndale Home For The Elderly DS0000001451.V360459.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.V360459.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 and 5. The home does not provide intermediate care standard 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are properly assessed before admission, making sure their needs can be met. Contract arrangements are clear and people have enough information about the service to make an informed choice about its ability to meet their needs. EVIDENCE: People spoken with said they were given the opportunity to visit and assess the facilities and suitability of Ferndale. In people’s case files, there was evidence of comprehensive pre-admission assessments. This provides details of people’s condition, health and other professionals’ involvement with the individual. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 10 People spoken with said they had received a contract and they all said that they had enough information about the home before they moved in. As part of the assessment process, information about people’s lives, family, occupation, their preferred way of living including daily routines, hobbies and interests, personal care preferences, spiritual needs and food preferences are taken. From all of the information collected, a plan of the care needed is written. Ferndale Home For The Elderly DS0000001451.V360459.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 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s care needs are met in a way that respects their privacy and dignity. People’s health care needs are met, although more work is required with the maintaining of medication records. EVIDENCE: There was evidence in records showing that people have access to GPs (General Practitioner), chiropodody, dental and optical services. The medication system was looked at, storage facilities are secure, however the accompanying record sheets are not always accurately completed which could put people at risk of been given medication more than once. There was evidence of people’s wishes in respect of end of life care and these are recorded. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 12 There was also evidence that care plans are updated as and when needs change. Care plans are reviewed monthly. From discussions with people living at the home, and from the returned completed survey forms, it is clear that they feel that their dignity and privacy are respected. “Staff always knock on my door before entering” “I could see whoever I want in my room”. People living in the home looked well cared for. From discussion with staff, it was clear that they knew the precise needs of the people living in the home and provided care based on individual needs and preferences. When asked about one person, they were able to tell me what kind of food he liked and what activities he liked. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a relaxed and informal atmosphere that promotes flexibility and visitors are made to feel welcome. People are encouraged to take part in social and leisure activities and a good and varied diet is provided. EVIDENCE: Menus are varied and nutritionally balanced. These are developed after consultation with people in the home at meetings or on an individual basis. Meals are served in the dining room or people may have their meals in their own room. The dining room tables are arranged in small group settings. This encourages conversation and makes meal times a social occasion. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 14 The mealtime was relaxed and anyone who needed assistance at meal times was given this discreetly and with courtesy. All the people spoken with said they enjoyed the food. The lunchtime meal seen on the day was attractively presented. During the inspection visit, staff were seen providing activities to people that were identified in the person’s plan of care. The manager said outings take place but, due to the age group and disabilities of most of the people, this is not very often. Most of the people require one-to one and wheelchairs, so only small numbers of people could go out at one time. In conversations, people clearly expressed that they follow their preferred ways of living – getting up times, going to bed, whether to spend time alone or with others, what activities to join in and what to wear. All the people living in the home were well dressed and looked well cared for. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their representatives can be confident that their concerns will be listened to and dealt with. The home has the necessary systems in place to make sure that people are protected from abuse. EVIDENCE: The home has a comprehensive policy and procedure on the action staff should take if abuse is suspected or reported. In discussion with staff they all appeared confident in the action to be taken. People spoken with said information on how to make a complaint was made available to them and all said they know how to complain. The manager was aware of the need to report any suspected or alleged abuse to the local authority and other relevant authorities. Relatives said information on how to make a complaint was made available to them and they know how to complain. Policies are in place aimed to set out how the home protects people using the service and prevents harm or abuse and this includes a whistle blowing policy. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,24,25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely environment that is clean, comfortable, and generally well maintained making it a nice place to live. Access to most bedrooms and all bathrooms is restricted for those people who cannot climb stairs. EVIDENCE: The home has two bathrooms, one of which has been converted into a shower room to offer people more choice. There is a stair lift to the first floor but people still have to climb a flight of three stairs to reach all of the bedrooms on this floor and the home’s two bathrooms. This makes it difficult for people Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 17 with bedrooms on the ground floor to get baths because they cannot easily access the bathrooms. The manager said further investigations are taking place to the possibility of a downstairs bathroom extension. However, if this is not addressed, it could affect any new admissions to the home. It could also affect current people living in the home when their needs and mobility deteriorate. All the people living in the home spoken with said the home was always clean and free from offensive odours. Gloves and aprons is used by all staff and infection control procedures and policy are in place. There was a choice of lounges, which anyone could choose to sit in. Bedrooms reflected different personalities of the people living there. Everyone seemed happy in his or her own domain. There is a maintenance personnel/gardener employed to ensure that the environment is kept safe and any specialist maintenance required is done by professionals. A couple of loose floorboards requiring attention were pointed out to the manager and maintenance person. All fire safety equipment is maintained on a quarterly basis and alarm tests are done weekly. A new fridge freezer and fridge have been purchased for the kitchen and the kitchen has been tiled making it a lot easier to keep clean. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff employed is sufficient to meet the needs of people in the home. They have received sufficient training to ensure people’s needs are met in a satisfactory way. EVIDENCE: All the people spoken with and surveyed said generally the staff are excellent. Comments from people living in the home were; ‘they are kind and helpful’ ‘very friendly staff’, ‘all staff are gentle’. Mandatory training courses such as Health and Safety, First Aid and Manual Handling are attended by all staff, as are other relevant training courses such as Food Safety, Adult Protection, Infection Control, Safe Administration of Medicines and Dementia. With the exception of two of the staff files looked at, all included necessary documentation such as two references, Criminal Record Bureau enhanced disclosures, contract, application forms and interview information records. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 19 Missing from two files were contracts and one person had an incomplete application form and no written references. The manager said the owner knew that person personally and felt references were not needed. It was pointed out to her that anyone employed to work in the home must have references which helps to ensure the people living in the home are protected and safe. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in a manner that promotes good service delivery in the best interests of people living there. EVIDENCE: The registered manager has a certificate in management and has vast experience of caring for the elderly. People talked with during the site visit explained how the manager had responded to any concerns they had about the quality of the service. Meetings are held to enable the manager to obtain the views of the people living there. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 21 Staff members spoken with during the site visit said they felt supported by the management and their views were listened and responded to. There is a rolling programme of formal supervision and regular staff meetings take place. The Annual Quality Assurance Assessment returned states all of the recent health and safety visits have been carried out and the home works to a health and safety policy. Staff spoken with said they had health and safety training as part of their induction. Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 22 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 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 x 2 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13 Requirement Medication record sheets must always be accurately completed otherwise people could be put at risk of been given medication more than once. The home must consider ways to make bathrooms accessible to all people living in the home. Floorboards that are loose must be attended to. This has the potential of becoming a trip hazard to people using the building. All job application forms must be completed fully and two written references taken up to help ensure the people living in the home are protected. Timescale for action 01/05/08 2 OP19 23 (a) (j) 01/05/08 3 OP19 23 01/05/08 4 OP29 12 01/05/08 Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ferndale Home For The Elderly DS0000001451.V360459.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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