Inspection on 10/10/06 for Fernhaven

This inspection was carried out on 10th October 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

Fernhaven 19/01/06

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

CARE HOME ADULTS 18-65 Fernhaven 5 Derbe Road Lytham St Annes Lancashire FY8 1NJ Lead Inspector Denise Upton Unannounced Inspection 10th October 2006 09:30 Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernhaven Address 5 Derbe Road Lytham St Annes Lancashire FY8 1NJ 01253 781199 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) Mr Islamuddeen Duymun Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered to accommodate a maximum of 6 service users in the category MD (mental disorder) 19th January 2006 Date of last inspection Brief Description of the Service: Fernhaven Care Home provides residential accommodation for up to six service users with a history of mental illness that do not require nursing care. The property is a semi detached three-storey house, with good access to the local services and amenities of St Annes. These facilities can be accessed independently or with the assistance of staff as appropriate. The homeowner/manager and support manager both have extensive experience of supporting people with a mental illness. Emphasis is placed on providing longterm rehabilitation in order for service users to maintain and extend independent living skills. Service user accommodation is located on the ground and first floor of the building and offers individual bedroom accommodation to all service users. Communal areas of the home are comfortable and well maintained and consist of a lounge and separate dining room. A designated smoking room is available on the first floor of the home. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning and early afternoon period of a mid weekday. At this visit, all of the core standards identified in the National Minimum Standards, Care Homes for Adults (18-65) were assessed as well as a reassessment of the recommendations highlighted at the last inspection. At the time of this inspection, there were six service users living at the home. The inspector spoke to the homeowner/manager, support manager and a member of the care staff team. A number of records were examined and a partial tour of the building took place. Brief general discussion also took place with all service users during the course of the visit. In addition, more in-depth individual discussion took place with four of the people living at the home. The Commission for Social Care Inspection service users comment cards, made available prior to the inspection also providing feedback. This provided further information on how service users felt that Fernhaven Care Home was meeting their needs and requirements. Information was also gained from a pre inspection questionnaire completed by the homeowner/manager. What the service does well: Fernhaven Care Home has an established staff team who know the service users well and work hard to make sure service users are well cared for. There are good links with mental health services and service users are encouraged to participate in courses and activities available. People who live at the home are also encouraged to make decisions and choices for themselves and to determine their chosen lifestyle. Service users spoken with felt that they were well supported and that they had a good relationship with the staff team. The home has a good system in place to make sure that the needs and requirements of a prospective service user are clearly known before they are admitted. This is to make sure that the staff can provide a service that is suitable for that specific person. The home also has good systems to make sure that the views and opinions of service users are known to enable service users to suggest changes such as menu suggestions. Service users spoken with said that the food was good and plentiful with a good choice offered. Service users are encouraged to keep in contact with their family and friends who are free to visit at any time. Service users were also satisfied with their bedroom accommodation and communal rooms at the home. Fernhaven DS0000065618.V311867.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. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A well-established and detailed pre admission assessment process is in place to ensure that individual needs and requirements could be met and the home could provide the service required. EVIDENCE: Fernhaven Care Home has a well-established system in place, which ensures that a thorough assessment of current strengths and needs takes place before a new service user is admitted. This process also incorporates the outcomes of any other recent multi disciplinarily assessments that are available. This detailed and comprehensive pre admission assessment process ensures that the prospective service user’s strengths, needs and wants and wishes are known and it is considered that they can be addressed. Since the last inspection, three new service users have been admitted to the home. There was clear evidence of a detailed Care Programme Approach care plan and risk assessment as well as a further professional assessment of a specific need with regard to one on the recently admitted service users. There was also evidence of the comprehensive single Care Management (health and social services) assessment and care plan that had been received from the prospective service user’s Care Manager prior to admission. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 9 In addition, the management team at Fernhaven Care Home had undertaken a further independent assessment of strengths and needs/risk assessments and the service users had completed a client’s personal profile. Collectively this information provided detailed information to enable the homeowner to make an informed decision as to whether current strengths, needs and requirements could be met. The collated pre admission assessment information then formed the basis of the initial care plan. All of the recently admitted service users confirmed details of the assessment process and also stated that they had been consulted about their wants and needs and wishes prior to living at the home. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a clear and consistent care planning and risk assessment system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: During the course of the inspection, three service users were ‘case tracked’. This involved looking carefully at all the information that is kept by the home regarding the help, encouragement and support required to ensure that the individual service user can enjoy the lifestyle of their choice. All service users have an individual plan of care that tells staff what the service users strengths and needs are and how the wants and wishes of each service user can be achieved. Service users are invited to contribute to their individual care plan that includes relevant risk assessments. This is to make sure the service user is involved as much as they wish to be, in developing and reviewing their care plan. All care plans are reviewed on at least a six monthly basis with more frequent reviews taking place soon after admission or when Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 11 required. Care plans were signed by the individual service user to acknowledge their understanding of and agreement to the outcome. Service users spoken with confirmed that they are encouraged to make their own decisions and are provided with information and assistance in order to make informed choice. Details of local advocacy services are provided, although in practice the individual service user’s social worker/community psychiatric nurse will usually undertake this role. It was evident from observation of care plans that individual choices have been made by service users and recorded appropriately. The individual care plan incorporates elements of the Care Programme Approach care plan, identifies risk assessment strategies and positive planned interventions to assist the service user to maximize their potential. Service users are provided with verbal information on how to maximise their own personal safety to avoid limiting the service user’s choice. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Links with the community are good and support and enrich service users social and educational opportunities. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choice. EVIDENCE: Fernhaven Care Home continues to offers service users opportunity for continued personal development and to take part in valued and fulfilling activities. One service user spoken with has recently commenced the second year of a part time degree course at a local university and stated he was still enjoying the course and “it is nice to meet other people” and socialise with them. The home has good links with a local mental health resource centre and a number of service users attend this venue. A variety of courses are offered and currently service users are enjoying activities that include computer skills, cookery, a walking group and a music group. Staff are also keen to encourage Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 13 service users to participate in activities in the local community and try hard looking at individual skills and exploring things that the individual service user may enjoy. As a result of this, one service user has taken up tai kuando lessons. A number of service users have chosen to have Sky television in their bedrooms and a variety of ‘in-house’ activities are also available that includes day trips out in the mini bus and meals out. Although some service users have generally low motivation, all service users are encouraged to access local library services with a number of service users continuing to use the internet library facility. All service users at Fernhaven choose daily occupations that they wish to become involved with. This however can incorporate Care Programme Approach (CPA) decision-making outcomes particularly in respect of any therapeutic employment opportunities that service users may choose to access. Staff would also assist the service user to develop appropriate employment skills in conjunction with the individual social worker/care manager All service users and some staff are racially and culturally similar. However Fernhaven Care Home does accommodate service users with different diversity needs that are respected and promoted. Staff support is offered flexibly and in accordance to individual wants and needs. One recently admitted service user stated that the home “is suiting me very well and I am improving, I feel safe here. Social relationships are always encouraged. Family and friends can visit the home at any time of the service users choice. Likewise, service users are enabled to maintain existing family and friendship links or alternatively develop new friendships. Several service users spoken with explained that there had recently been a birthday party at Fernhaven with the ladies from the Fernhaven’s sister home invited. This party has been “very much enjoyed” Service users health is promoted by ensuring a nutritious, varied and balanced diet that is designed round the known likes and dislikes of service users accommodated. There was clear evidence of menus being determined through service user consultation. Questionnaires had been provided to identify what service users would like to be incorporated in the new menu. Although some of the suggestions made could have been nutritionally unbalanced, the new menu has been designed to incorporate all suggestions while maintaining a healthy diet. Service users spoken with were pleased with this and spoke positively about the variety and quality of the meals served. If required, diets in respect of cultural, religious or medical need could be accommodated that would be identified during the assessment process. Risk in respect of excess alcohol consumption is acknowledged in the home with Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 14 certain service users encouraged to restrict alcoholic intake to moderate levels only. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Personal support is offered in such a way as to maximise resident’s lifestyle choices. The physical and mental health care needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Service users at Fernhaven Care Home are mainly self-caring and at most require prompting and encouragement in order to undertake personal care tasks. However service users are regularly assisted with lifestyle support as identified on the individual care plan that is determined by the strengths, needs, wants and wishes of each individual. Routines within the home are individualised to accommodate individual requirements and service users spoken with stated that they were comfortable with all members of staff, liked them and confirmed that they had choice and independence when determining their life style. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 16 Although service users are encouraged to experience a structured day, routines within the home are flexible with service users dictating when they choose to get up, go to bed and the individual clothes and hairstyle that reflect their personality. The home maintains close links with psychiatric services including community psychiatric nurses and mental health social workers and participates in regular multi disciplinary Care Programme Approach meetings. Service users select their own General Practitioner, are supported to manage their own individual healthcare requirements and have access to a range of health care professionals either independently or with the assistance of staff when required. Service user’s health including mental health is monitored by the home and prompt referral to the appropriate professional secured if there is concern. Fernhaven Care Home has good systems in place to ensure the safe management and accurate recording of medication. Recommendations made at the last inspection with regard to medication issues have been implemented to good effect. All staff that have responsibility for medication administration have undertaken part 1 of an extended modular medication course and a number of staff have also completed a part 2 qualification of the same course. This external medication course supplements the internal medication handling course that all staff are expected to undertake as part of the routine training programme. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Fernhaven Care Home has developed a good complaints system and adult abuse policy and procedures for the protection of service users. EVIDENCE: No complaint or concern has been made in respect of Fernhaven Care Home for some considerable period of time. The home’s complaint procedure is compliant with requirements and incorporated in the written information provided to newly admitted service users. The policy outlines the home’s commitment to providing a written acknowledgement of any complaint received with two working days and to resolving complaints wherever possible within 28 days. Service users are encouraged to voice any concerns and complaints immediately so that issues can be discussed and addressed. Service users spoken with were aware of the written formal complaint information and were also clear as to who they would speak with if they did have a complaint. The home also has a robust policy and procedures in place for protecting service users from possible abuse. This topic also forms part of the mandatory training provided to all staff. A variety of other policies are also in place to protect service users that include, whistle blowing, restraint, and service users monies. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The premises are in keeping with the local environment and are in close proximity to local facilities and services to suit the personal and lifestyle needs of service users accommodated. The home is arranged over two floors and is comfortable and well maintained. Furnishings are domestic in character and provide welcoming and attractive accommodation. All service users are provided with individual bedroom accommodation. Service users currently accommodated are all independently mobile with no physical mobility difficulties. In order to promote independence, service users are encouraged to attend to their own washing or other domestic tasks, with the assistance of staff as required. Service users spoken with were all pleased with their individual bedroom accommodation that is personalised to suit the occupant, and the communal space available. Since the last inspection, some redecoration has taken place Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 19 and a new carpet purchased for a service user’s bedroom. In addition, a desk has been provided to enable another service user to study more comfortably. Fernhaven Care Home has a variety of policies and procedures in place for the control of infection and safe handling of waste products including clinical waste and dealing with spillages. Laundry facilities are situated in an outbuilding and away from kitchen and dining areas and do not intrude on service users accommodated. The home complies with the requirements and recommendations of the Environmental Health Department and health and safety requirements to meet the needs of service users accommodated. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff morale is high resulting in a group of staff that work positively with residents to help improve their quality of life. The standard of vetting and recruitment practices within the home are structured with appropriate checks routinely being carried out that help protect service users from risk or harm. Staff training is seen as a priority to ensure staff have the skills and knowledge to provide a good quality service. EVIDENCE: Fernhaven is a smaller type care home with a family type atmosphere. The majority of staff have worked at the home for a considerable period of time and know the needs, wants and wishes of service uses very well. Each service user is very much an individual and the relationship observed between staff and service user is comfortable and positive. One recently admitted service user stated that he got on well with all the staff and stated “I am pleased that I am here, I get on well with the other people and the staff have helped me a lot. It is right for me now”. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 21 Staff training at Fernhaven Care Home is viewed very positively to ensure a high quality service. Two members of the management team are registered mental health nurses and a senior carer is currently undertaking the Registered Managers Award that is an advanced Nationally Recognised qualification for managers of care homes. Other members of staff have either completed or are undertaking a National Vocational Qualification (NVQ) in care. In addition, staff collectively have a variety of qualifications that include counselling, medication, and challenging behaviour. All staff also undertake a variety of health and safety training courses. All newly appointed care staff undertake the ‘Skills for Care’ induction training programme and each member of staff has an individual training and development assessment and profile indicating current training requirements. Since the last inspection, one new member of staff had taken up employment at the home. The staff file of this person was observed and confirmed that the recruitment practices followed were in accordance with requirements and recommendations. Appropriate references and clearances had been obtained and deemed to be satisfactory before the new member of staff commenced employment at the home. As part of the recruitment process, all prospective employees spend time with service users in order to elicit the service users views and opinions as to their suitability, which is taken into account when offering the post. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homeowner/manager is well supported with all staff demonstrating a good awareness of their role and responsibilities. The home regularly reviews aspects of its performance through a programme of self-review and consultation with service users and staff. Systems are in place to ensure as far as possible the health and safety of service users, staff and visitors. EVIDENCE: The homeowner/manager is a registered mental health nurse and has extensive experience of supporting people with a mental illness. The homeowner/manager commenced the Registered Managers Award but due to personal reasons, this has recently lapsed. However it is anticipated that this course of study will recommence in the near future. The homeowner/manager Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 23 has however undertaken recent additional training to ensure his skills and knowledge are kept up to date. Systems are in place to ensure that service users views and opinions about living at the home are known. This includes informal daily dialogue with staff and regular service user meetings. Periodic service users questionnaires, to allow service users to say what they think and to have some say into how the home is run have been less successful with service users preferring a more verbal approach to obtain their views and opinions. Staff views and opinions that can also influence change are highlighted in staff meetings minutes and through regular formal supervision. Relatives and friends of service users are also enabled to make their views known through written questionnaires. This helps to identify if the home is meeting service users needs and requirements. It has been disappointing however that although questionnaires have been provided to professional staff that are involved with service users, none have been completed or returned. The majority of staff have sucessfully completed all recommended health and safety training that included a fire safety awareness course, health and safety in the work place course, moving and handling training, first aid training and medication training. It is anticipated that all staff will have completed all of the recommeded health and safety training elements within the next few weeks. A written statement of the policy, organisation and arrangements for maintaining safe working practices is available. Fire risk assessments are in place that is specific to an individual that includes smoking in communal areas. Environmental risk assessments are also undertaken when a risk has been identified to minimise that particular risk. Equipment is regularly serviced and a number of up to date certificates were evidenced that includes fire safety equipment, electrical installation certificate, small appliance testing certificates and gas certificate. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Refer to Standard YA32 Good Practice Recommendations The registered provider/manager should complete the Registered Managers Award. Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Fernhaven DS0000065618.V311867.R01.S.doc Version 5.2 Page 27 - 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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