Inspection on 11/11/05 for Ferndale Mews

This inspection was carried out on 11th November 2005.

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

The inspector 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 Mews 14/11/07

Ferndale Mews 06/02/07

Ferndale Mews 22/07/05

Ferndale Mews 25/01/05

Ferndale Mews 06/08/04

Ferndale Mews 23/02/04

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Chirnside House

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Thornton Lodge

Emmaus House

East Croft Grange

Craignair

Alfred House Residential Care Home

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

CARE HOMES FOR OLDER PEOPLE Ferndale Mews St Michaels Road Ditton Widnes Cheshire WA8 8TD Lead Inspector Anthony Cliffe Unannounced Inspection 11th November 2005 09:00 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 Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ferndale Mews Address St Michaels Road Ditton Widnes Cheshire WA8 8TD 0151 495 1367 0151 424 4363 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) Southern Cross Healthcare Services Limited Mrs Eileen Geraghty Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2) Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 34 service users to include :* Up to 34 service users in the category DE(E) (Dementia over 65 years of age) * Up to 2 service users in the category MD(E) (Mental disorder excluding learning or dementia over 65 years of age) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance whci may be issued through the Commission for Social Care Inspection 22nd July 2005 2. 3. Date of last inspection Brief Description of the Service: Ferndale Mews is a care home providing personal care for 32 older people with dementia who may also have physical disabilities and 2 people diagnosed with mental disorder. The home is located in the Ditton area of Widnes, close to local shops, pubs and St. Michaels church. The building is a storey purpose built home on the same site as Ferndale Court Care Home. All the bedrooms are single with en-suite facilities. There is a passenger lift. The home has a large secure rear garden. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by a regulatory inspector. The inspection took place over seven hours and feedback was given to the manager at the end of the inspection. It included inspection of records, observation of staff practice and discussion with residents and staff. No requirements were identified at this inspection visit. What the service does well: What has improved since the last inspection? What they could do better: Provide additional hot storage during meal service and alternative choices of a sweet at meal times. Give feedback to the manager on information received on anonymous satisfaction surveys. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 7 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 Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Assessments of needs are completed, before residents move into the home, to ensure their needs can be met. EVIDENCE: The records of residents who had recently moved into Ferndale Mews were examined. A new standard pre-admission form is completed as part of the preadmission assessment and this was supplemented by a dementia assessment. The pre admission information includes the resident’s previous mental health history and history of physical illness and current medication. It incorporates a number of assessments to determine the residents’ level of dependency, risk to developing pressure ulcers, nutritional needs and risk of falling. Incorporating the dementia assessment this document provides information from which a care plan to meet residents’ can be developed prior to moving in. A care plan is then developed prior to the resident moving into the home. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8. Residents’ plans ensure that health and social care needs are identified and met. EVIDENCE: The records of residents were examined, including those of residents who had recently moved into Ferndale Mews. New standard documentation has been introduced as part of the merger of Southern Cross Healthcare and Highfield Care. This uses a detailed pre admission assessment and dementia assessment. The pre admission information includes the resident’s previous mental health history and history of physical illness and current medication. It incorporates a number of assessments to determine the residents’ level of dependency, risk to developing pressure ulcers, nutritional needs and risk of falling. Incorporating the dementia assessment this document provides information from which a care plan to meet residents’ needs can be developed. Prior to moving in a care plan was developed for a resident who recently moved into Ferndale Mews. The care plan covered all the needs of the resident identified pre admission. The care plan identified that the resident was independent of needs and required prompting to meet her personal care needs. Residents’ key workers as recommended are transferring all existing care plans into the new format at the previous inspection visit. Care plans had Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 10 been reviewed as recommended at the previous inspection regarding the recording of best practice used by staff to manage residents’ aggressive and challenging behaviour. The care plan review for the management of this behaviour included observations by staff on the triggers to these episodes. Monitoring of the behaviour was also completed to identify if there were any triggers or patterns to the behaviour. The care plans and risk management plan informed staff on the good practices described in managing challenging behaviour and identified what actions staff should take to diffuse or prevent the situations arising. Care plans recorded that residents were receiving treatment form the dietetic services and speech and language therapist and the advice from the speech and language therapist regarding a residents with swallowing difficulties was incorporated into the plan of care. A resident who had recently moved into the home talked about the care she receives and said ‘ I recently moved here from Runcorn, the place is lovely, comfortable a bit of a home from home but no quite. I have my own bedroom, which is large and comfortable with its own toilet. The people are nice and I am well looked after. I would say I am well cared for, its what you make of it. The people and staff are nice and I am nice to them. We get good food, not as nice as the food I served, but still nice. Il like the manager she’s all right, she speaks to me regularly to see if everything’s ok’. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a variety of choice in their diet but the choices of meals, serving and storage of food needs to improve so residents receive a choice of meal served at the correct temperature. EVIDENCE: At lunchtime on the ground floor residents had the choice of eating in the dining room, lounge or their bedroom. The meal was served from a hot trolley brought over from the main building. The choice of meal on offer was poached fish or battered fish with mushy peas and chips. A resident on a soft diet had chosen a fried egg instead of poached fish. Meals were served onto plates and then taken to residents. As soon as the main meal had been served the kitchen assistant served the pudding, which was fruit sponge and custard. If residents did not want this there was fruit in the dining room, which was not brought over with the meal. Main meals and sweets served and not yet eaten by residents were left on the top of a kitchen unit until they were requested. There was a microwave oven to reheat main meals or sweets if necessary. Staff commented that recently there was no alternative sweet on offer and the kitchen usually supplied yoghurt. The menus on display were those for the previous two days and not the one for the 11th November. The kitchen assistant verified that meals were served like this as there was only one hot trolley and she had to serve meals to residents on the first floor. Staff were Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 12 available to assist residents. One resident who sat in the lounge was not eating her dinner as her posture was incorrect and she was leaning to one side. Staff promptly corrected her posture with support from pillows and the resident ate her meal independently. If residents did not want this there was fruit in the dining room, which was not brought over with the meal. See recommendation 1. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The homes adult abuse training and procedures protect residents. EVIDENCE: As recommended at the last inspection staff employed at Ferndale Mews had read the policy on the use of physical intervention. Staff interviewed confirmed they had to read this so they were clear on the use of physical intervention. Staff said they had also been instructed not to physically hold any resident who was resistive to personal care but ‘to leave the resident to calm down and then attempt to assist them later, if they are aggressive then we are to distract them’. An agency carer said she had not read the policy on the use of physical intervention despite being instructed to on two separate occasions by senior staff. The manager confirmed her awareness of this. Five care staff, maintenance man, activities organiser and domestic staff had undertaken training on the management of challenging behaviour in September 2005 and further training had been arranged. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Residents live in a safe and well-maintained home, which is clean and hygienic. There is a commitment to improving the standard of accommodation for the benefit of residents. EVIDENCE: Internally the building continues to be improved with the decoration of the first floor dining room and several bedrooms. The manager confirmed that the main corridor carpets on the ground and first floor are planned for replacement, as these are now looking tired and worn. The environment of the home was free from odours. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The skill mix and numbers of staff is adequate to meet residents’ needs. EVIDENCE: The staffing numbers in the home had been increased by the manager with the introduction of a twig light shift between the hours of 18.00 to 22.00. This increases the staff in the home between these hours. The hours are currently used Monday to Friday but can be flexible to include weekends. Ferndale Court has continued to operate with the manager supernumerary to the staff rota and the deputy confirmed that she has supernumerary hours to undertake management duties. Between the hours of 08.00 and 14.00 there is a senior care and four care staff on duty. Between the hours of 14.00 and 18.00 1 senior care and four care staff. Between the hours of 18.00 and 22.00 1 senior care and five care staff. Between the hours of 22.00 to 08.00 1 senior care and two care staff. The manager said that there are vacancies at Ferndale Mews and a total of 66 agency staff hours per week are currently used. Staff have been interviewed for these posts. An activities organiser is due to commence employment at the end of November who will work 30 hours a week. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38. There is a competent manager employed at Ferndale Mews that gives leadership guidance and direction in the home to ensure residents receive consistent quality care. EVIDENCE: The manager, deputy manager or a senior carer undertakes a weekly audit of medicines. Recently a number of errors were found and the deputy manager and senior carers received additional supervision form the manager and operations manager. Additional training has been arranged for these staff. Senior staff also completes weekly audits of care plans and the new documentation is being used for all residents. The manager completes a monthly audit which covers all aspects of the home including; Inspection outcomes. Protection of vulnerable adults, complaints, residents meetings, pressure ulcers, accidents, medicines and health and safety. The health and safety aspect of the audit includes; electrical maintenance, gas installation, fire, COSHH, risk assessment of working practices, maintenance and the Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 17 building. The handyman tests the water outlet temperatures over a period of a month as part of the health and safety audit. The operations manager completes monthly visits under Regulation 26 of the Care Homes Regulations 2001. Each month the manager sends out a percentage of the Southern Cross Healthcare satisfaction survey, which are returned to the managing director. No feedback from these is given to the home and the manager confirmed approximately 40 had been sent out by her. The manager commenced a relatives form meeting on 25th October. Thirteen relatives attended this and an agenda used. The meeting was attended by the operations manager. Relatives requested that compliments, complaints and suggestions book was commenced and these items could be fed back to future meetings. Also a secure comments box for those relatives who did now wish to talk in public was suggested. The home does not deal with any residents’ finances except for personal spending money. Otherwise residents control their own money or have relatives who assist them. Residents have personal money in safekeeping. Receipts are given to relatives for money paid in. Residents’ money is kept in separate envelopes; all transactions are recorded and double signed on a receipt given by the administrator; receipts for all expenditure made on behalf of residents are filed and the reference number transferred onto the computer system for cross referencing. The manager provided details of the testing and servicing of all plant and equipment. The records maintained within the home relating to the health & safety of residents was examined. These included; Fire Log Book, Accident Book, Risk Assessments, Portable Electrical Appliance Tests, HACCP Records Maintenance Records for Hoists and Records of Discharged Hot Water. Fire drills and fire training have been held in April, June and October 2005. A weekly fire alarm test is recorded and weekly emergency lighting test. See recommendation 2. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 18 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 x x 3 Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP33 Good Practice Recommendations There should be additional storage for meals so they are served at the correct temperature. A choice of sweets should be made available at mealtimes. Feedback from satisfaction surveys returned to the managing director should be made available to the manager of Ferndale Mews. Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ferndale Mews DS0000005188.V261933.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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