Inspection on 14/12/06 for Ferngrove House Care Centre

This inspection was carried out on 14th December 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 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

Ferngrove House Care Centre 09/02/09

Ferngrove House Care Centre 25/02/08

Ferngrove House Care Centre 06/05/05

Ferngrove House Care Centre 22/09/04

Ferngrove House Care Centre 08/06/04

Similar services:

Chirnside House

Emmaus House

East Croft Grange

Craignair

Croston Park Nursing Home

Conifers Nursing Home

Cloisters

Elmsdene Care Home

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

CARE HOMES FOR OLDER PEOPLE Ferngrove House Care Centre Blackstone Edge Old Road Littleborough Lancashire OL15 0JG Lead Inspector Sue Donovan Unannounced Inspection 14th December 2006 08:00 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 Ferngrove House Care Centre DS0000025471.V315481.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. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferngrove House Care Centre Address Blackstone Edge Old Road Littleborough Lancashire OL15 0JG 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 378938 01706 379919 Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 36 service users in the category of DE(E) Dementia over 65 years of age. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The newly appointed Manager must make application to register with CSCI by 28th August 2006. Rooms numbered, as 30, 31, and 32 must not be used as personal accommodation. The Registered Person must ensure that all staff working in the home have dementia care training, which equips them to meet the assessed needs of the services users accommodated, as defined in the individual plan of care. The service should at all times employ suitably and experienced members of staff, in sufficient numbers, to meet the assessed needs of the service users with dementia. A revised Statement of Purpose and Service User Guide, in a format suitable for intended service users, must be provided to the CSCI by 1st September 2006. Work on the interior of home, to assist residents with audio and visual clues must be completed by 30th September 2006. 6th May 2005 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Ferngrove House, part of the Southern Cross Group, is a care home providing accommodation and personal care for up to 36 residents on both a permanent and respite basis. The home is a conversion of two period semi detached houses that have been extended and modernised during 2006 to provide a home on three levels. Local shops and amenities are a short drive away from the home. There is ramped access to the front of the home with adequate parking. Safe enclosed garden areas are available at the rear of the home. The rooms and facilities of the home are spread over three floors with a passenger lift available to all levels. All rooms are single and vary in size they all have ensuite toilets. There are three lounge/dining areas, one large lounge on the ground floor has a bar area and two smaller lounges on the second and third floors. The toilets and bathrooms on all floors have aids to assist residents. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told the inspection was to take place. The site visit took place over an eight-hour period from 8am to 4pm. The report was written after looking at the information sent to the commission for social care inspection (CSCI), including a comment card and after talking to the residents, their friends, the manager and staff and looking around the home. During the inspection, care and medicine records were looked at to make sure resident’s needs were being met. The inspector looked around the building to check if it was clean and well decorated. The inspector looked at the food that was provided for breakfast and lunch and checked records to see how the home and the equipment were kept safe. A copy of the service user guide was available in each bedroom. No complaints had been received by the CSCI since the last inspection. Residents said, “it’s very nice here,” “they are lovely to me,” and “the staff are superb.” What the service does well: The home specialises in caring for people who have dementia and the staff are trained in this area. Currently only the ground floor of the home is being used. This is homely, well furnished, very light and contains many features to help the residents find their way around the home. For example all the bedroom doors are painted different colours. The manager and staff know residents well and spend time making sure they are cared for the way they need to be. A resident said, “whatever I ask for, it just appears.” Activities are arranged for residents to enjoy and benefit from everyday of the week. Good meals are provided and a good choice is available. A friend of a resident said, “the care is superb.” Ferngrove House Care Centre DS0000025471.V315481.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. Ferngrove House Care Centre DS0000025471.V315481.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 Ferngrove House Care Centre DS0000025471.V315481.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): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Up-to-date information is given to residents and their families to enable them to make a decision as to the suitability of the home. Prospective residents have their needs assessed prior to admission to assure these will be met. EVIDENCE: A statement of purpose and service user guide was provided in resident’s rooms. The statement of purpose (SOP) included the admission criteria and complaints procedure. The service user guide (SUG) showed what residents could expect when living at Ferngrove House. The new manager had only been in post for two weeks at the time of the inspection and her details had not yet been added to the SOP and SUG. The manager said she was planning to rewrite the SUG involving residents, using photographs and large print. An example of the new format to be used was seen and was easy to understand giving good relevant clear information. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 9 Three residents files were inspected and each contained evidence of the homes assessment for both funded and self-funding residents. On two files evidence was seen of Social Services department care managers assessments. A discussion took place with the manager regarding the assessment process that was undertaken when someone wanted to come and live at the home. She said that she visits the person at home or in hospital and they are invited to look around the home and spend time there. The admission information seen on residents files was comprehensive and included pre-admission assessment and on admission assessment. This information contained medical history and some good personal comments for example, “likes to have a lie in at weekends,” and “likes to have a bitter at meal times.” A checklist is completed on admission this showed good detail and included the kitchen being informed of the resident’s birthday. All assessment information had been used when writing the care plans. A comment card returned by a social care assessor said that the home communicated clearly and worked in partnership with them and that the staff demonstrate a clear understanding of the care needs of residents. Ferngrove House Care Centre DS0000025471.V315481.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. The care planning system in place provides staff with the information they need to meet resident’s needs. The medication system was safe, but times that medication was given to residents needs to be monitored to ensure they receive medicines when they need them. EVIDENCE: Three care plans of residents were looked at. The plans contained information about how to care for the residents. Completed care plans showed health and personal care needs and recorded the actions to be taken to meet these needs. There was evidence on files that staff were reviewing care plans on a regular basis (at least monthly) and staff confirmed that they input in reviewing the content of care plans so the care reflects what the resident needs. A member of staff said, “ I always talk to the team leader if I think changes are needed to the care plan.” Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 11 Information also included life profiles that showed some detailed information of resident’s interests, past careers, likes and dislikes. One file showed a resident enjoyed sport and the manager said they were arranging for X to attend a rugby match. Personal journals were being planned for all residents that would give greater detail of what residents past interests had been, life history and memorable events in their life, these will help make sure a person centred service is provided. A visitor did say, “the care is superb.” There was no evidence seen that residents and relatives had been involved in the compiling of care plans or had signed to agree the content of the plans. Care plans recorded the involvement of doctors, district nurses and other health care professionals including visits by the chiropodist and the optician. Residents were weighed monthly and their weights monitored, one file showed a resident had lost weight and the plan had been altered to make sure their food intake was monitored closely. Nutritional assessments and records of food and fluid intake were also completed. Good practice was seen with jugs of juice and water available constantly in the lounge area. Risk assessments were in place and up-to-date these included assessments for residents who were at risk of falling. The activity programme at the home encouraged residents to keep active, residents were seen on the day of inspection involved in activities that encouraged them to stretch and move around. Staff said the garden area was used when weather permitted. Medication policies and procedures were in place. Trained staff administer medication, the certificates of staff were seen and staff confirmed that they had attended training. A staff-training list was also seen on the staff notice board showing a medication course was taking place the day after the inspection. Most medication was supplied in a monitored dosage system (MDS) with preprinted medication administration records (MAR). Medication appeared to be given and signed correctly, however on the day of inspection the morning medication was administered at eleven am. This needs to be monitored to ensure that the time between dosages is as prescribed and medicines to be taken with food are administered with food. The medication storage was orderly and secure. It was observed that staff administering medication wore a bright red medication tabard so other staff and visitors knew not to disturb the person during the administration of medicines. A new drugs refrigerator was in place but no temperatures were recorded. The recording sheets were found with the refrigerator instructions and staff started to complete them immediately; this should be continued twice a day. On the day of the inspection site visit observations showed that personal care and hygiene needs were met in a discreet and sensitive way. Staff spoke Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 12 quietly to residents when encouraging them to move to the dining area and gave residents the time they needed. Staff were observed knocking on residents doors before entering. Residents said, “they are lovely to me,” “I’m very comfortable,” and “whatever I ask for it appears.” Ferngrove House Care Centre DS0000025471.V315481.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. Social activities that residents enjoyed were provided enhancing the enjoyment and fulfilment of residents. Visiting arrangements at the home are good, ensuring links between residents and their families and friends are maintained. A good choice of food that was well balanced was provided for resident’s enjoyment and wellbeing. EVIDENCE: An activities co-ordinator was employed on a part-time basis she currently works two days per week. Activities on the day of inspection included painting figures, games and hand massage. The activities board displayed events that had been arranged for the Christmas period; make a pomander, a party for friends and relatives and a concert by a local school. Staff said that some community activities had taken place and this was an area the manager wished to develop. The manager said that she had recently attended a conference ‘with care and commitment’ and felt that activities and Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 14 hobbies were an important part of life that should be continued when people live in a care home. She encourages staff to understand that activities are not just the co-ordinators role but all staffs and the team use the booklet ‘the southern cross guide to accessing activities’ for ideas. Staff were observed on the day of inspection supporting residents with the activities. The residents visited other homes within the area and an interagency darts league sometimes visits the home. A well-fitted hairdressing salon was on the ground floor of the home and the hairdresser visited twice weekly. All the female residents visited the hairdresser on the day of inspection. The hairdresser said that she enjoyed coming to Ferngrove House, felt it was well organised and that the facilities were good. The home had an open visiting policy. A friend of a resident said, “I can call in whenever I want.” Residents can see their visitors in any area or in their rooms. A visitors book showed the times people had visited. Residents are encouraged to bring personal possessions into the home. Bedrooms were highly personalised with some of their own furniture, pictures, photographs and ornaments etc. At the time of inspection no faith groups were holding services at the home but the manager said that this could be arranged if a resident requested it. The choices residents made each day varied, but residents were generally free to choose what time to get up, go to bed, what clothes to wear, what to eat (within the choices of the day) and whether to participate in activities. Residents were seen getting up over a three-hour period in the morning. Two residents had independent advocates who visited them on a regular basis. Menus inspected were seen to provide a nutritious and varied diet over a fourweek period. The cook said that a choice of two hot meals was usually served at lunchtime and two more choices were provided at teatime. There was always five fruit and vegetables incorporated into the menu each day. Good practice was seen with a large bowl of fresh fruit being made available to residents a mealtimes. Breakfast and lunch were observed. Currently only the dining area next to the lounge on the ground floor is in use and this was set with tablecloths, flowers and condiments. At breakfast some residents ate bacon on toast while two residents choose cereal. Fresh orange juice and a hot drink accompanied the meal. One resident said, “ the bacon butty was lovely.” Lunch was chicken in a cream sauce with potato wedges or rice followed by apple crumble and custard. A resident said, “its good food here.” It was noted that breakfast was not served until ten o’clock on the day of the inspection and the residents that had risen early had only been offered a drink Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 15 and a biscuit, it was discussed with the manager that an alternative should be offered and the time of breakfast should be flexible. Suitable provision was made for those needing a special diet i.e. diabetic. Food intake was monitored for those that were unwell or had poor appetites. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 16 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. A complaints procedure was in place but not in a user-friendly format or displayed in the home to make sure that resident’s complaints would be listened to. Appropriate systems were in place to protect residents from abuse whilst living at Ferngrove House. EVIDENCE: The home had a complaints procedure that was included in the service user guide, a copy of which was provided in each bedroom. A complaints log was available but had no complaints recorded in it. The CSCI had not received any complaints since the home was registered. Developing a user-friendly complaints poster was discussed with the manager and this should be displayed in the entrance area of the home for residents and all visitors to see. A procedure for responding to allegations of abuse (including whistleblowing) was available but the home did not have a copy of Calderdale’s and Rochdale’s safeguarding adults policies, these should be obtained by the manager. Staff spoken with understood the importance of reporting bad practice and had received training in this area as part of their induction. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 17 One protection of vulnerable adults (POVA) investigation had taken place this year at the home. This had been reported and investigated appropriately as per the procedure. One resident said, “I feel safe here.” Staff are not employed at Ferngrove House without checks being made, these include criminal records bureau (CRB) and two satisfactory references being received. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, clean, pleasant, hygienic and well-maintained building was provided for resident’s comfort. EVIDENCE: Ferngrove House is a large home situated on the outskirts of Littleborough. The home had safe garden area for residents to spend time in. The gardens could be developed in the future to provide more seating areas and raised beds so residents who wished to could enjoy gardening. The home was safe, well maintained and clean. Inspection of the maintenance records showed that small repairs were done quickly, discussion with the maintenance worker supported this. The television in the lounge only had a portable aerial and the picture quality was poor, this should be rectified to provide better reception. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 19 Currently only the ground floor of the three-story home was in use. The lounge, dining room and bar area were well decorated and contained numerous items of memorabilia. Good practice was noted in helping residents familiarise themselves with their surroundings by for example painting changes in levels bright yellow to warn residents, painting bedroom doors different colours and fitting them with door furniture. The home was generally clean, hygienic and free from unpleasant odours on the day of inspection. Policies and procedures were in place with regard to infection control. Staff were provided with disposable gloves and other personal protective equipment. Liquid soap and paper towels were near hand washing facilities. Staff were observed to be maintaining good hygiene practices. The pre-inspection questionnaire noted that the environmental health officer had visited the home 05/10/06 and that the fire officer had visited 28/07/06. The laundry was sited away from food preparation areas and was seen to be clean. Sufficient and suitable equipment was provided but a working surface and shelving were needed to store baskets holding residents personal clothing and reduce the amount of bending and lifting by staff. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were on the rotas to meet the needs of residents. Some timekeeping problems were apparent that could affect the service provided to residents. Recruitment and selection policies supported and protected residents. A few staff had a formal qualification that helped them to do their jobs. EVIDENCE: Inspection of the rotas showed that sufficient staff were planned to meet the needs of residents. However on the day of the inspection only one member of staff was in the building for a short period of time and two ancillary workers were very late for work on the same day. The manager should monitor the timekeeping of staff as this could have an affect on the quality of the service provided to residents. Observation showed that residents had a good trusting relationship with staff. Residents said, “staff are super,” and “they are lovely to me.” Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 21 All care staff had been recently appointed. One of the care staff had a National Vocational Qualification (NVQ) level 2, other staff spoken to said they were enrolling to start the award. Inspection of three staff files showed that CRB checks that the home had applied for were all in place for staff and that all staff had completed an induction programme. Staff spoken with said that they had shadowed staff for three weeks and had completed the Southern Cross induction workbook. Training records were seen for the three staff and showed the training that had taken place since their recruitment. Training included, dementia awareness yesterday, today and tomorrow fire awareness first aid pova moving and handling. Ancillary workers were fully included in the training above and staff commented that they had found the dementia awareness course very useful. Staff said “the residents always come first,” “I like caring and interacting with the residents” and “it’s like a family.” Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 22 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 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective leader and quality assurance systems are in place to ensure residents can voice their opinion. The home has systems in place that are properly managed so that resident’s financial interests are safeguarded. EVIDENCE: Ferngrove House has undergone changes in management of the home since it first opened .The new manager has had six years experience in care. She has an NVQ 2 and is enrolling for the registered managers award. During her first few weeks as manager an experienced manager from another home was supporting her for two days per week and the district manager one day per Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 23 week. Staff said the manager was, “great, she respects the staff team,” and “lovely, you can go to her with any problems.” The manager needs to register with the CSCI. The home had a quality audit policy this includes annual surveys. These are carried out to gather the opinions of relatives and other stakeholders, the results of the surveys are published. Customer comment cards are given to relatives and suggestions taken on board. The manager said she holds a weekly surgery when she works later and is available for anyone to talk to. Residents and relatives meetings are to be held. The home is planning on holding six monthly reviews this is the policy of the company to make sure the service provided is what the resident needs, relatives and other professionals involved are invited to these. The responsible individual has conducted regular visits to the home as required by regulation 26. Copies of these have been received by the CSCI. The system for safeguarding resident’s money was good. Their families generally undertake the management of resident’s finances. Only personal allowances are held for any purchases made. Individual computer records were seen of all transactions and balances. As the manager was only recently appointed frequency of supervision could not be looked at but one staff file did have evidence that a meeting had taken place and the manager said she felt supervision was important and was planning supervising staff every six weeks. The home had a detailed health and safety policy. Regular weekly checking and testing of the fire detection system, fire exits and emergency lights were undertaken and documented a fire risk assessment was in place dated November 2006. No health and safety hazards were noted during the inspection. The home employed a full-time maintenance person who was organised and thorough. Ferngrove House Care Centre DS0000025471.V315481.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 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? First inspection 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 OP27 Regulation 18 (1)(a) Requirement The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of service users. Timescale for action 30/12/06 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 OP1 Good Practice Recommendations The registered person should consider developing the service user guide in a user-friendly format using for example photographs/large print so everyone can understand the information. The registered person should involve residents and relatives in developing the care plans and agreeing there content. The registered person should audit the times that medication is administered to ensure the period of time between dosages is as prescribed. The registered person should consider arranging more DS0000025471.V315481.R01.S.doc Version 5.2 Page 26 2. 3. 4. OP7 OP9 OP12 Ferngrove House Care Centre 5. 6. OP15 OP16 7. 8. 9. 10. OP18 OP19 OP19 OP26 11. OP28 12. OP31 community access in line with resident’s personal interests. The registered person should arrange for breakfast to be served over a longer period of time for residents that wake early. The registered manager should develop a user-friendly complaints procedure for everyone to understand and this should be displayed in the entrance so residents and visitors understand how to make a complaint. The registered person should obtain copies of Rochdale and Calderdale’s safeguarding adults policies. The registered person should consider developing the enclosed garden areas to provide an attractive area for residents to enjoy. The registered person should arrange for the portable aerial in the ground floor lounge to be replaced so residents have a good reception on the television. The registered person should arrange for shelving and a working surface to be fitted in the laundry so the baskets holding residents clothing can be stored off the floor and staff have a safe working area. The registered person should aim for 50 of staff to be qualified to NVQ 2 level. New staff should enrol in the first six months of their employment to provide a trained workforce to meet the needs of residents.. The manager should register with the commission for social care as the registered manager and be suitably qualified for the role of manager (NVQ 4) within two years. Ferngrove House Care Centre DS0000025471.V315481.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Ferngrove House Care Centre DS0000025471.V315481.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!