Inspection on 14/11/07 for Ferndale Mews

This inspection was carried out on 14th November 2007.

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 06/02/07

Ferndale Mews 11/11/05

Ferndale Mews 22/07/05

Ferndale Mews 25/01/05

Ferndale Mews 06/08/04

Ferndale Mews 23/02/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Chirnside House

Ashwood Court Unit 1

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 Joan Adam Unannounced Inspection 09:30 14 November 2007 th 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.V351729.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 Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale Mews Address St Michaels Road Ditton Widnes Cheshire WA8 8TD 0151 495 1367 0151 424 4363 ferndalemews@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Ltd 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) Carol Elizabeth Cummins 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.V351729.R01.S.doc Version 5.2 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) Date of last inspection 6th February 2007 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. The current charges for the home are £485 to £839 per week. This information was provided by the acting home manager. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit, part of the key unannounced inspection of the home, took place over 7 hours. It was carried out on 14th November 2007 by two inspectors. The findings were discussed with the acting manager on the 14th November 2007. Before the site visit the manager was asked to complete an Annual Quality Assurance Assessment to provide information as part of the inspection. The views of the people who live at the home and their relatives were also sought; their comments are incorporated into this report. During the site visit the inspector spoke to the manager, some staff members and people who live at the home. Five people’s records were looked at to check the care they receive. Policies, procedures and records of medication, care plans, staffing rotas and training records were also checked. What the service does well: The needs of residents are fully assessed by the acting manager before they are admitted to the home so they know that their needs can be met. All residents have a care plan in place which contains adequate information so that staff know how to meet their needs. Medication management at the home is good so that residents receive their prescribed medications. Residents are offered choice in their daily lives and the standard of catering is good. Residents are treated as individuals and their privacy and dignity is respected. Recruitment procedures, staff training and staff supervision ensure that residents are protected from harm. Residents’ financial interests are also safeguarded. The home is clean and comfortable with a warm and welcoming atmosphere. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Mews DS0000005188.V351729.R01.S.doc Version 5.2 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.V351729.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust admissions procedure ensures that all prospective residents have their needs assessed, and are assured that the home has the capacity to meet their needs, prior to admission. EVIDENCE: The care plans for two recently admitted residents (one in September 2007 and one in October 2007) were looked at. They each contained a copy of the local authority funding agreement. Both had very good records of a thorough pre-admission assessment carried out by the acting manager, which showed that the home would be able to meet their needs. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 9 A draft care plan had been written. For one of these residents, the family had filled in an excellent social history. A senior care assistant said that this was a great help for the staff getting to know a new resident. The home does not provide intermediate care therefore standard 6 was not assessed. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. Individual plans of care ensure that residents’ health and personal care needs are met. Medications at the home are well managed to ensure that residents receive the correct prescribed medication at the right time. EVIDENCE: Three care plans were looked at in detail. The care plans for residents admitted in September 2007 and October 2007 had been very well written. Care plans were written in appropriate language and showed that individual needs were identified, for example: X prefers his own company. Very private man. Staff to encourage but not overwhelm him. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 11 The folders are organised so that at the front is the daily report sheet, daily hygiene sheet and (where required) elimination record. Good entries were made each day to show the care that had been given and how the resident was that day. The folders contained full assessments for pressure sore risk, moving and handling, nutrition, continence, and falls risk. These assessments had been reviewed monthly but where a change was identified they had not always been amended and updated. For example, the falls risk assessment had not been updated for a year for a resident who had a serious fall in September 2007 and another fall in October 2007. The weekly progress summaries were generally very good however; the activities record sheets did not appear to be used. One of the care plans had a good record of communication with the resident’s spouse including a formal review every six months. It was clear that staff did not understand how to completed the tool used for assessing the nutritional risk. The acting manager and the deputy confirmed this. However, residents had been weighed monthly and this was recorded. The care plans recorded visits from doctors, district nurses, continence advisor, community psychiatric nurse and other medical professionals. The care plans for three residents with weight loss were looked at. One of these people had significant weight loss over last six months. A chart was being used for daily intake monitoring. The care plan did not reflect this monitoring, and a weekly rather than monthly weight might be considered. Another person had a gradual but significant weight loss over the last year. This could have been better reflected in her care plan, to show what action was being taken. These issues were discussed with the acting manager and deputy manager and they assured the inspectors that the dietician was fully involved with reports being sent to her on a monthly basis. The home had a friendly and pleasant atmosphere and good relationships were seen between the residents and staff with friendly banter taking place. When assisting with meals or drinks they sat beside them and encouraged them to take what was offered. Staff were seen knocking on the doors of residents before entering and talking to the people who live in the home in a respectful manner. Residents spoken with said,” I like living here” “ it is a lovely place to be” “ the staff are lovely” Relatives were spoken with and comments such as “ I couldn’t look after my mother any better myself” “ The care is second to none” “ the staff communicate well with the residents” “ the staff take time to get to know them” Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 12 The medicines storage room is on the ground floor and there are two separate trolleys, one for each floor of the home. Identified senior staff are trained to administer medicines. The is usually one senior member of staff for each floor but sometimes at night only one senior. The medicines room was tidy and orderly with an air conditioning unit to keep the room cool. Storage was good apart from a few items of old stock in a cupboard that should have been returned to the pharmacy. This was dealt with immediately Good systems are in place for ordering, storage, administration and recording of medicines. A controlled drug cupboard and controlled drug record book were used mainly for night sedations. A monitored dosage system is used. Administration records were excellent with no missed signatures. Where a variable dose was prescribed (for example one or two tablets) the quantity given was recorded. Staff sign a sheet at the end of each shift to confirm that all medicines have been given as prescribed and signed for. The sheet is also used to report any missed signatures, any out of stock items or other queries that have been identified. Ferndale Mews DS0000005188.V351729.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives spoken with were positive about the home and the support they received so they could maintain contact with friends and family and make choices about their daily lives. EVIDENCE: Residents were seen to move around freely within the home and a choice of sitting areas was available. Routines appeared to be flexible and residents were assisted to get up at varying times of the morning. Staff members were seen to knock on the door and to await permission before entering a resident’s bedroom. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 14 A variety of social and other activities are organised by the activities coordinator and a list of activities on offer were displayed on the notice board. Activities on offer are manicures, hairdressing, sing-a -longs, bingo, reminiscence, exercise to music and one to one sessions with residents to read newspapers or magazines. A weekly cookery club has commenced and residents can make their own bread and cakes with the help of staff. Outside entertainers are booked at the home on a regular basis. Religious preference is recorded in the care plan and ministers from the local churches visit the home regularly to hold services. Residents were seen being taken to a local café and for a walk around the area of the home. Visitors are free to visit the home at any reasonable time. The home has a conservatory, which at present is not being used. The acting manager has ordered new furniture and equipment for this area. The room is to be sectioned off to enable a café area to be made so that residents can share a meal with their relatives in a private setting. Tables will be booked as in a restaurant. The remainder is to be used as a sensory room with a water feature, projector, relaxing music and sensory lights to enable residents to relax. Meals can be taken in the dining room or in the privacy of residents’ own rooms. There is a menu that has the flexibility to meet individual needs and choices. All of the residents that commented said that the food was good and that choices were available. Special diets are prepared where necessary. Residents and relatives said that the food at the home was good. Residents said that they got enough to eat. Ferndale Mews DS0000005188.V351729.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are acted on to demonstrate they are taken seriously. An informed staff group and manager protect residents from abuse. EVIDENCE: There is a clear complaints procedure for the home. The information received from the acting manager prior to the inspection taking place indicates that no complaints have been received during the previous 12 months. However, two issues that had been raised by relatives had been dealt with by a care review, which was fully documented. The relatives spoken with during the visit confirmed that they knew what to do if they were unhappy or wanted to make a complaint. One relative said,” the home is really good, there is nothing to complain about” There are policies and procedures to guide staff on how to make sure that the people who live at the home are protected from harm or abuse. There is also a whistle blowing policy that tells staff how they can make any concerns known. The manager is aware of the appropriate procedures to follow should an incident arise. Staff members have received training in this area. Ferndale Mews DS0000005188.V351729.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): 19,21,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained so that the people who live there live in comfortable, safe surroundings that suit their needs. The bathrooms need to be reassessed to better meet the needs of the residents EVIDENCE: A tour of the premises was undertaken; this included the communal areas and a number of bedrooms. Furnishings, fittings and lighting in the communal areas are of a good quality. Since the last inspection visit the acting manager Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 17 has put photographs and large nameplates outside each bedroom door, which has also had, a doorknocker and letterbox installed. Each door will be painted in a colour of choice, such as the colour of the residents’ front door when they were living at home, to enable them to find their own room more easily. Most bedrooms have been redecorated and re-carpeted and a pagoda and water feature have been ordered to improve the garden area for the residents. Bedrooms seen during the inspection were personalised, comfortable, wellfurnished and contained items of furniture belonging to residents’. The home provides adaptations for use by residents with mobility problems: these include bath and toilet aids, hoists, grab rails and wheelchairs. The laundry is appropriately equipped and good systems are in place for the care of peoples’ clothes. Two of the bathrooms on the ground floor at the home have floor covering that is stained and is coming away from the wall and drain area. This is allowing water to gather underneath the floor covering and is a health and safety and infection control hazard. The staff are finding it difficult to bathe and shower residents and one of these bathrooms is out of use. The bathroom opposite the care office could be better utilised as a wet room with some of the room used for storage. The bathroom next to room three has a bath in situ which is not suitable for residents who need assistance and staff are inappropriately bending to wash residents. The home should assess the bathing needs of all residents in the home and a more appropriate type of bath should be installed to enable all residents to choose whether they want a shower or a bath. The home was clean and fresh on the day of inspection. Ferndale Mews DS0000005188.V351729.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good recruitment process in place to ensure that staff are suitable to work in the home but staffing levels need to be reviewed at night to make sure that the needs of people living at the home are always met. Staff recruitment ensures that residents are protected. The training programme needs to improve to provide a skilled workforce that protects residents’ welfare. EVIDENCE: Duty rotas were looked at and the staffing levels discussed with the acting manager. There appears to be adequate numbers of staff on duty during the day, however, after 10pm, there is only one staff member on the first floor until 8 am. It was felt that this should be reviewed as if the staff member was attending to a resident other residents safety may be compromised. Staff training had taken place and courses attended were care planning, moving and handling, first aid, protection of vulnerable adults up dates, yesterday, today and tomorrow, fire training. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 19 The training for staff to achieve NVQ level 2 has increased. At present 6 staff have achieved NVQ level 3 and 6 staff have achieved NVQ level 2 in care. The home has 70 of care staff with this qualification. Five staff personnel files were seen during the visit including three newly employed staff members. These showed that thorough recruitment procedures are in place including two references for each member of staff and a Criminal Record Bureau Check. Ferndale Mews DS0000005188.V351729.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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well managed home with safe financial procedures and equipment to meet their needs and effective quality assurance systems in place to make sure that the home is run in the best interests of the people who live there. EVIDENCE: The home is at present being run by an acting manager. She was previously the deputy manager and has worked at the home for some time. She has NVQ level 3 in care and has recently been enrolled to commence NVQ level 4. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 21 Improvements had been made in the home such as care plan recording, accident recording and Regulation 37 notices were now being sent to CSCI to inform us of incidents that took place regarding residents. Areas of the environment were also being improved such as the bedroom doors and the use of the conservatory since she has been in post. Relatives spoken with said she was “open and honest “. One said, “The atmosphere at the home is lovely and warm” Staff spoken with felt she was supportive and listened to their views. There were monthly audits completed by the acting manager that covered care plans, accidents, pressure ulcers and treatments, medication, the building including; kitchen, laundry and standard of cleanliness, and notifiable incidents. The area manager visits the home unannounced on monthly basis and a report is compiled and a copy is sent to CSCI. Residents’ personal allowances were safely secured and records for credits and debits maintained. Fire records showed that fire detection equipment is tested by contractors regularly through the year and weekly alarm tests are carried out. There were good records of regular fire drills, including the names of the staff attending. Information provided by the acting manager prior to the inspection (Annual quality Assurance assessment) stated that all the required maintenance and health and safety checks of the building and equipment had been completed. Ferndale Mews DS0000005188.V351729.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 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 Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 23 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 OP21 Regulation 23(2)(b) Requirement The bathrooms at the home must be assessed to enable all residents to have a choice of whether they require a bath or a shower and to enable staff to assist in safety. Staffing levels at night must be reviewed to ensure that people’s needs are met and that they are do not have to wait for long periods of time before getting the help they have called for. Timescale for action 31/01/08 2 OP27 18(1)(a) 31/12/07 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 OP7 Good Practice Recommendations Care plan recording should be more detailed with regard to the weight loss of residents. Ferndale Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Mews DS0000005188.V351729.R01.S.doc Version 5.2 Page 25 - 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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