Inspection on 28/11/06 for Marriners Group

This inspection was carried out on 28th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marriners Group 09/03/06

Marriners Group 09/08/05

Marriners Group 21/02/05

Marriners Group 13/07/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Ferndale House 32 Ferndale Grove Frizinghall Bradford West Yorkshire BD9 4LF Lead Inspector Karen Westhead Key Unannounced Inspection 28th November 2006 08.40a Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 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 House DS0000001156.V318176.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale House Address 32 Ferndale Grove Frizinghall Bradford West Yorkshire BD9 4LF 01274 772619 N/A lydasante@yahoo.co.uk 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) Heaton Community Care Mrs Lydia Asante Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: Ferndale House is registered to provide care for three people with mental health problems and is operated by the Mariners Group. The current residents are all female, and have lived at Ferndale House in excessive of four years. The home is located on a quiet street in the Frizinghall area of Bradford and is close to the main bus routes, local train station and local amenities. Accommodation is provided on two floors and includes three single bedrooms, a communal bathroom, and kitchen and lounge/dining room. There is a small yard at the back of the house. Parking is on street. The current weekly fees are £290.36. This fee does not include toiletries, hairdressing, some social activities or transport and papers/magazines. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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. All regulated services will have at least one key inspection between 1st April 2006 and 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area e.g. medication or food provision and are known as random inspections. This visit was done by one inspector and had not been prearranged with the Manager. The inspector arrived at 8.40am. At the end of the visit, the manager was told how well the home was being run and what needed to be done to make sure the home met the standards. A pre-inspection questionnaire was sent out to the home in September 2006. It was returned completed, a month later. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with requirements. Before the inspection information received about the home was reviewed. This included looking at the completed pre-inspection questionnaire, the number of reported incidents and accidents, the action plan provided following the previous inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. A number of records were looked at during the visit; all areas of the home were seen. The inspector also talked to all three residents, the manager and staff. CSCI comment cards and post-paid envelopes were left with residents to complete. Two have been returned. The comments received are included in this report. What the service does well: Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 6 Ferndale House is a small family sized home. The atmosphere is relaxed and comfortable. The checks in place make sure the people working at the home are suitable. The records about care are well written and give the reader an accurate picture of the needs of each resident. Residents are involved in their plan of care and sign to say they agree with it. Staff take notice of what the residents need and work well to carry out the advice of doctors and other health professionals. Residents said they were given lots of opportunities to take control of their lives and decisions, which affect them. Residents receive a good quality of care. Staff make sure residents keep in contact with people who are important to them. Residents make full use of the local and wider communities. What has improved since the last inspection? What they could do better: The home is comfortable and suits the residents living there. However a number of things were brought to the deputy manager’s attention, which needs to be done to make sure the home meets standards. • • • • • • • • Records about medication need to be up to date. Unused medication needs to be returned to the chemist. Surplus furniture needs to be removed if the fire officer says it cannot be stored in the attic room. Thermostats need fitting to the hot water taps to make sure residents do not get scalded. Light fitting need to be in working order. Residents need suitable locks on their bedroom doors so that they can have some privacy. Staff should be able to get into the room in an emergency and in case of fire. Windows need to be fitted with restrictors if necessary to meet Health and Safety and fire safety rules. Checks must be in place to make sure staff are all right to work with residents receiving care. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 7 • • A proper system needs to be in place to protect staff and residents when staff are on duty alone. A certificate is needed to make sure the electrical wiring in the home is all right. 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 House DS0000001156.V318176.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of residents are fully met at Ferndale House. Their needs are reviewed all the time to make sure the staff are able to meet them. The contract they have been given sets out what they can expect whilst living at the home. EVIDENCE: Two of the residents have lived at Ferndale House for ten years. The third resident moved in four years ago. Therefore there have been no new admissions. The original assessments were held on file. It was clear that the residents had had a say about whether they moved in or not. Each of the residents had been provided with a contract, setting out what the terms and conditions of their stay were. Two were seen and had been signed by the resident. The deputy manager said contracts were renewed if any changes occurred. For example, a change in fees. However, there had not been any changes over the last two years. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 10 Risk assessments had been up dated to included recent information. Staff work with other health professionals to make sure they are providing the best possible support to residents. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in decision-making and play an active role in the planning, care and support they receive. Care plans include information, which matches the care each resident needs. Staff make sure verbal and written information is kept confidential. EVIDENCE: The attitude of staff and the running of the home put the rights of residents first. Residents are supported in taking and keeping control of their lives. Staff talked to the inspector about how they were able to support the wishes of residents. All the residents said they were able to keep control over decisions, if they wanted to and that staff gave them ‘sound advice’ if they were unsure about something. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 12 Residents said they knew all of the staff and what their jobs were. The home does not have a nominated worker for each of the residents. The staff team is small and therefore run more informally. Two of the residents said they knew about their plan of care and sometimes read it and signed it. These residents said the information was true and matched what they thought they needed to stay well. Long and short-term goals have been set for each of the residents and these are discussed regularly with the residents. Staff has a good working knowledge of the need to keep residents details safe and their responsibilities around ‘data protection’. Records are kept properly and anything relating to staff is kept in a file at the main company office. These records were made available for the inspection visit. Residents are not isolated and have contact with other people concerned about their welfare who do not work in the home. This includes people who work for Social Services, the Health Authority, friends and family. Risk assessments are in place. The management of risk is planned and follows logical stages. For example, one risk assessment clearly showed what had happened to a resident in the past and what signs to look out for to avoid the risk becoming too high. Another risk assessment gave details of what behaviours to look out to make sure the resident did not pose a risk to herself. The focus is to keep the resident and others safe, without stopping them being able to live a meaningful life. A common sense way of measuring the risk has been applied and a structured plan has been put in place. There have been no incidents involving restraint, admission to hospital or injuries to residents. Staff have been trained to deal with challenging behaviour and were due to extend this training to include issues affecting people with a mental illness. Practices in the home are covered by the company’s policies and procedures. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a good social life. This includes leisure activities and attending courses at colleges and centres. Staff help residents to learn skills such as cooking and cleaning therefore making them more independent. Food is provided. But residents do some cooking and help with the shopping and preparation of meals. EVIDENCE: Residents said they take part in a lot of activities, which suit them. These fit with their age, peer group and cultural needs. Two of the residents go out independently and use public transport freely. One resident is a fan of Cliff Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 14 Richards and had been with a friend to see him in concert in Manchester recently. Another resident is in the middle of an Open University degree and fits this around caring a relative who lives near by. Staff are keen to enable the residents to reach their individual goals and follow their interests. This has resulted in residents signing on at local colleges and education centres. Ornaments and other pieces of art made by residents were on display in the home. Where needed, staff take residents out. Residents do make good use of the local community. Residents are enabled to maintain their independence. This includes residents taking responsibility for food preparation and cooking. The involvement of staff is determined by the skills and abilities of each resident. A mealtime was not seen during this visit but residents said food was good, well prepared and there was plenty to eat. They said meal times were flexible, apart from the main evening meal. Staff provide information on healthy eating. The home does not employ a cook. Staff are expected to plan and provide meals as part of their role. During the week, the main teatime meal is not cooked at the home. If residents are out, staff are sent to work at other places run by the company. Whilst there the meal is cooked and then taken to Ferndale House for reheating. Proper safe guards are in place to make sure the food is served at the right temperature and well presented. At weekends the meals are cooked at the home. The sample menus seen included a variety of dishes which residents said they liked. Residents talked about the relationships they had with family and friends. They said they were helped to keep links with others and helped to identify people that made them happy and those who might be detrimental to their welfare. Routines in the home are very flexible and are centred on what residents are doing. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents receive the care they need and illness is handled with respect and dignity. Residents can take charge of their own medication. However, the home is poor at recording medication and unused medication is not being returned to the chemist. EVIDENCE: Residents use a wide range of health care services. Residents are able to choose their own doctor, optician and dentist. A chiropodist visits Ferndale House every six weeks. Staff do attend appointments with residents if necessary. However, they make sure residents have the right to privacy. Medication records were checked and were not being completed properly. The record being used was out of date and some unused medication found in the drug trolley had not been returned to the chemist. Residents, who are able, collect, keep and take their own medication. Safeguards are in place to make sure residents follow their doctor’s instructions. Three doctors surgeries are used and residents can see if female or male doctor. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 16 Those residents taking control of their own medication have a drawer in their bedroom, which locks. Other medication stored in the home is kept in a medication trolley, which is kept in the lounge. Staff have information telling them the possible side effects of the medication being taken by residents. Therefore being able to take action if residents became unwell or affected. Staff have been trained to give out medication and have attended first aid training in the last twelve months. Where residents need reminding to carry out personal hygiene tasks, this is done discretely. Staff are mindful that ageing can cause difficulties for residents and are taking steps to make sure Ferndale House remains the right home. At the time of the visit, there was no need for any specialist equipment to be provided. All residents are able to climb the stairs and use the homes facilities. The deputy manager said residents who might find this a problem in the future will be reviewed and that where possible equipment would be provided. Staff have had discussions with residents about their wishes should they become ill. They have also talked about what their wishes would be in the event of their death. This is recorded in the plan of care. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the policies in the home. EVIDENCE: The home has an Adult Protection and Complaints procedure. Staff have had training about both of these. Since the last inspection the home has not had to deal with any complaints or allegations from residents. The staff said they felt that because the home was small, any minor concerns could be dealt with almost immediately. Any concerns reported of a more serious nature would be reported and action would be taken. Residents can be sure that their rights are protected and that they are safe from abuse. Residents plan of care covered this area of their wellbeing. The record showed the residents understanding and what staff had to do if any incidents or complaints were reported to them. Not all the residents are able to take charge of their own finances. Bradford Social Services audit the money belonging to one resident. Where money is spent on the residents’ behalf, this is recorded and receipts are provided to cover the amount spent. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ferndale House is of a suitable size for the three residents. The home is well maintained, however there were some things, which could compromise the health and safety of residents. EVIDENCE: Since the last inspection the new kitchen units and worktops have been fitted. The bathroom has been redecorated and the lighting over the stairwell and landing have improved. The communal areas in the home were clean and tidy. Residents gave the inspector permission to see their bedrooms. These had been personalised by the residents. Staff are to continue in their efforts to make sure residents keep their personal space clean and tidy, without overstepping the need for privacy and choice. Overall the home was clean and tidy. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 19 Five things which need to be done to make sure the home is kept safe and up to standard are: • Surplus furniture and beds must not be stored in the attic space unless the fire officer has agreed this in writing. • The temperature of the hot water must be controlled so that residents are not at risk of scalding. Thermostatic valves must be fitted to taps to make sure the temperature does not exceed the maximum allowed. • All light fittings must be in working order. • Residents must have a lock on their bedroom door. This must allow them to lock their bedroom door when using the room, give staff access in an emergency and comply with fire safety. At the time of the visit, padlocks were being used by residents to lock their doors. These could not be used when they were in their rooms. • Windows must be fitted with restrictors, which meet the requirements of the health and safety executive and fire safety officer. None of the laundry is dealt with in the home. It is done at another home owned by the company. Residents said they did not have any problems with this and there were no hold ups getting their personal items returned. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has enough staff to look after the three residents. However, a risk assessment is needed to take account of the fact that staff work alone at all times. Staff are caring and are committed to their work. Staff files did not contain all the required information. EVIDENCE: The company provides training throughout the year to make sure staff are able to carry out their duties. Recent training has included Adult Protection, Managing Challenging Behaviour and staff were due to go on a course about issues affecting people with mental illness. Staff are also doing external qualifications, which are recognised in the care sector. Recruitment procedures make sure all the necessary pre-employment checks are made before staff start work. Staff files are not kept at the home but were Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 21 made available for the inspection. On checking staff files some information was not included. One file did not contain two written references, one application form had no date and start dates did not match other information held. The deputy manager said the staff team was made up of three generations from one family and two had worked for the company for many years, before the stringent rules were in place when employing staff. Residents said the staff team did not have any problems when caring for their range of cultural and gender needs. No risk assessment has been completed despite staff working alone on every shift, including their sleeping in duty. The deputy manager said that the residents had not needed assistance during the night over the last twelve months. This was confirmed when checking resident’s daily records. However, the company must take responsibility for the lone worker and show that there are suitable procedures in place to protect staff and residents. The deputy manager said the company was in the middle of writing a policy about this. One residents bedroom is on the ground floor, two bedrooms are on the first floor and the staff sleeping in room is on the third floor. The residents said they knew where the member of staff slept and felt confident knowing there was a member of staff in the building during the night if they should need her. Staff said they were able to talk to the manager and deputy regularly and that they were supported by the management team. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Checks on the building and servicing of appliances is kept up to date. The home does not have a lift, nurse call system or hoists. The company must provide a certificate to confirm the wiring of the building is sound. Some unsafe working practices and poor record keeping was noted during the inspection. These are included in the body of the report. EVIDENCE: The pre-inspection questionnaire showed that the maintenance and service checks are up to date. However, it is not clear whether a certificate has been provided to confirm the homes electrical wiring is sound. This is in addition to the PAT testing of electrical appliances. The deputy manager said the gas installations had been checked in September 2006. Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 23 Policies and procedures are available to staff. The deputy manager said that all of these had been reviewed in April 2006 and brought up to date. Ferndale House DS0000001156.V318176.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X 2 2 X Ferndale House DS0000001156.V318176.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 YA20 Regulation 17(1)(a) Schedule 3 3(i) Requirement a) The registered person must make sure the medication records are kept up to date and are accurate. Timescale for action 17/12/06 2 YA24 b) Any unused medication must be returned to the chemist and a record made of the action taken. 23(3)(a)(ii); a) The registered person must 23(2)(j); make sure that any storage of 13(4) and furniture is in accordance with 23(2)(p) fire safety. b) Hot water outlets must be controlled to reduce the risk of scalding. c) All light fittings must be maintained in full working order. a) The registered person must make sure residents have a suitable lock to their bedroom door. Consideration must be given to privacy, access in an emergency and fire safety. b)Windows must be fitted with 10/01/07 3 YA26 23 and 13(4) 20/02/07 Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 26 4 YA33 19(4) and (5) 5 YA34 18 and 13(4)(c) 6 YA41 17(1)(a) Schedule 3 23 and 13 7 YA42 restrictors, which meet the requirements of the health and safety executive and fire safety officer. The registered person must make sure that staff recruitment procedures are robust and all necessary information is obtained and recorded. The registered person must make sure that when staff are working alone the necessary risk assessments and procedures are in place to protect the staff and residents. The registered person must make sure all the necessary records are in place and are accurate. a)The registered person must make sure the home is run using safe working practices and all reasonable steps have been taken to minimise risk. b)The electrical wiring must be tested by a qualified person and a certificate must be produced to confirm the wiring is sound. 17/12/06 17/12/06 17/12/06 20/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ferndale House DS0000001156.V318176.R01.S.doc Version 5.2 Page 27 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 House DS0000001156.V318176.R01.S.doc Version 5.2 Page 28 - 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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