CARE HOMES FOR OLDER PEOPLE
Ferney Lee Ferney Lee Road Todmorden Lancs OL14 5JW Lead Inspector
Liz Cuddington Unannounced Inspection 4th January 2006 14:45 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 Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 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. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ferney Lee Address Ferney Lee Road Todmorden Lancs OL14 5JW 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) 01706 815507 01706 816025 Calderdale MBC Mrs Jean Nicol Conway Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To accommodate one service user under 65 years of age - transitional care bed 10th May 2005 Date of last inspection Brief Description of the Service: Ferney Lee is a residential care home offering personal care and single room accommodation for up to 25 older people. Ferney Lee offers a permanent home as well as respite and transitional care for the people of Calderdale. The home is owned and managed by Calderdale MBC. Ferney Lee has been refurbished and meets current fire safety standards. The communal rooms are attractively decorated, well furnished, light and spacious. The private rooms are also well decorated and furnished. The home stands in its own grounds and has ample car parking. The home is set just outside Todmorden town centre within reasonable walking distance of the main road and bus routes. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. During the inspection I looked at fourteen of the thirty-eight National Minimum Standards. The remaining key standards, as well as some of the other standards, were assessed at the previous inspection in May 2005. Two of the three statutory requirements made at that inspection have been carried forward to this report, although both show significant improvements. I spoke with some of the people who live at Ferney Lee. Everyone said they were very happy with the care, support, meals and accommodation at the home. I would like to thank the ladies and gentlemen who live at the home for taking the time to talk to me and express their views. I would also like to thank the staff and manager for their welcome and hospitality. What the service does well: What has improved since the last inspection?
The Statement of Purpose now reflects the scope of the services offered at Ferney Lee. The service users individual plans of care have been reviewed and show considerable improvements since the last inspection. A system of regular individual supervision for staff has been put in place. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 6 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. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 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 Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 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): 1&3 Standard 6 does not apply The Statement of Purpose reflects the scope of services offered at Ferney Lee. The pre-admission process is thorough. EVIDENCE: Ferney Lee’s Statement of Purpose has been re-written to reflect the services the home provides. All the individual plans of care I examined show that comprehensive preadmission procedures have been followed to ensure the home can meet the potential service users needs. The plans of care are, at first, based on this initial assessment of the person’s care and support needs. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 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&8 The plans of care do not always show that the service user or their representative has been involved in developing them and agreeing any changes. Staff do not always appear to follow up any changes they notice in an individual’s condition. EVIDENCE: The plans of care have improved since the last inspection and now contain the information needed including risk assessments, moving and handling plans and regular reviews. Some reviews showed that the individual or their next of kin had agreed to the plan, but others did not. If there is a reason why the service user or their representative is unable to agree the initial plan or review, this needs to be documented. Although there is written evidence that changes in an individual’s condition have been noticed, such as a new pain or unusual weight loss, the plans do not show that any action has been taken to address the concern which has been identified. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 10 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): 12,14 & 15 The right to exercise personal choices about all aspects of daily living is supported and encouraged. The menus offer a varied choice of good, appetising food. EVIDENCE: The people who talked to me said that they are able to make choices about all aspects of their daily lives. People are still involved in the life of the local community and are given support and encouragement to continue with their chosen activities. The people who commented said how nice the food is and that they enjoy their meals. I looked at the menus which offer a good variety of freshly prepared dishes. On the day of the inspection the teatime meal was a choice of soup, salad and cauliflower cheese with cakes and scones to follow. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 11 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): 16 & 18 The complaints and adult protection procedures are robust and, when needed, are followed through rigorously. EVIDENCE: As a local authority home the complaints and adult protection procedures are those used throughout Calderdale Social Services. They are thorough and robust. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 12 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): None of these standards was inspected on this occasion. EVIDENCE: Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 13 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): 28, 29 & 30 More staff need to achieve an NVQ qualification in care. The home follows the local authority’s thorough recruitment procedures. The training available for new and continuing staff is comprehensive. Some of the staff have not yet attended an adult protection training course. EVIDENCE: Seven members of staff have achieved an NVQ level 2 qualification in care and two have the level 3 qualification. One staff member is working towards NVQ level 2 and another towards level 3. This does not yet reach the minimum 50 of staff who are expected to have gained this qualification. The recruitment procedures include all the necessary checks to make sure new staff are suitable to work with vulnerable people. This includes obtaining two satisfactory references, Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks as well as completing a satisfactory interview. All new staff undertake induction training followed by a longer period of foundation training. There is a wide choice of short training courses available to make sure staff keep their skills and knowledge up to date. More staff need to attend the Protection of Vulnerable Adults training. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 14 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, 36 & 38 The quality assurance systems would benefit from further development. The records of service users financial transactions were not all accurate. The kitchen is kept as clean and hygienic as possible. The old wall and floor tiles are in a poor condition and the extractor needs a deep clean. EVIDENCE: Regular residents’ meetings are held, chaired by a volunteer from Age Concern. The minutes of the last meeting are displayed on the notice board. In addition to the visits and reports by a senior manager and the quality audits undertaken by the home’s manager, it would be beneficial for a more developed quality assurance system to be in place. This would provide valuable information from service users, their relatives and visiting professionals about how the home can further improve its services. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 15 Monies held on behalf of service users and records of the transactions were examined. One record was inaccurate, to the benefit of the service user, but the rest were accurate and the monies tallied with the balance sheets. The kitchen is spacious and kept as clean as possible. The storeroom is clean and in good order. When the home was refurbished the kitchen floor tiles and some of the wall tiles were left in place. These are, in many cases, cracked or broken leaving areas where it is not possible to clean thoroughly enough to maintain a good standard of hygiene. The extractor system above the cookers was installed during refurbishment. It is in need of a thorough deep clean to return it to a hygienic condition. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 16 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 17 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 OP7 Regulation 15 Requirement The individual plans of care must show that the service user, or their representative, has been involved in developing and reviewing the plan. Timescale for action 31/03/06 2. OP8 13 This has been carried forward from the last inspection. Previous timescale: 30/09/05 28/02/06 The plans of care must demonstrate that all aspects of each individuals health care have been assessed and all needs are attended to appropriately. This has been carried forward from the last inspection. Previous timescale: 30/09/05 Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 18 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. 3. 4. Refer to Standard OP28 OP30 OP33 OP38 Good Practice Recommendations More staff need to complete the NVQ level 2 qualification in care in order for the home to meet the standard. More staff need to attend the Protection of Vulnerable Adults training. The quality assurance systems would benefit from further development. The extractor system in the kitchen is dirty and would benefit from professional deep cleaning. Many of the kitchen wall and floor tiles need replacing. They are cracked and broken, causing them to become unhygienic. Ferney Lee DS0000034939.V255480.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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