Inspection on 19/01/06 for Fernhaven

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/10/06

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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 19th January 2006 10:00 Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 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.V277356.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 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.V277356.R01.S.doc Version 5.1 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.V277356.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to accommodate a maximum of 6 service users in the category MD (mental disorder) 9th September 2005 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 when appropriate. Since the last inspection, the registered provider at Fernhaven Care home has changed from Mrs Mary Duymun to Mr Islamuddeen Duymun who has extensive experience of supporting people with a mental illness. Emphasis is placed on providing long-term 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.V277356.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during a midweek morning period and lasted approximately three hours. The inspector spoke individually with the senior carer on duty and a member of staff who was undertaking domestic tasks. In addition, individual discussion took place with four of the six residents living at the home. A number of records and policies and procedures were examined and a partial tour of the building took place that included communal areas of the home, some bedroom accommodation and laundry facilities. The majority of the core standards regarding Care Homes for Adults had been assessed at the last inspection that took place in September 2005. The outstanding seven core standards were assessed at this inspection along with a reassessment of the requirement and recommendations identified at the last inspection. What the service does well: This is a care home where residents are well looked after and staff work hard to provide a high quality service. The staff team work well together, have a good relationship with all the people who live at the home and show a good understanding of the needs and wants and wishes of each individual resident. Residents spoken with were comfortable living at the home and got on well with the staff team. Routines within the home are flexible so that the people who live there can enjoy the lifestyle of their choice. Visitors are made welcome at any time of the resident’s choice and residents are also encouraged to go and visit their family and friends or develop new friendships in the local community. Residents are also encouraged to participate in educational opportunities and one resident was keen to talk about his college course and how this was progressing. All the residents spoken with were very satisfied with the communal areas of the home and their individual bedroom accommodation. The home is maintained to a good standard and provides a safe and comfortable environment for residents to live. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 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.V277356.R01.S.doc Version 5.1 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.V277356.R01.S.doc Version 5.1 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): None of the above five standards were assessed at this inspection. EVIDENCE: None of the above five standards were assessed at this inspection. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 9 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): None of the above five standards were assessed at this inspection. EVIDENCE: None of the above five standards were assessed at this inspection. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 10 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): 15 & 16 Links with family and friends and the local community are encouraged to support and enrich service users social and educational opportunities. Daily routines wherever possible are flexible to enable service users to enjoy the lifestyle of their choice. EVIDENCE: Social relationships are encouraged either through family/friends visiting at a time of the service users choice, service users visiting their family or friends in their own home or social stimulation in the wider community. Service users are enabled to entertain their family and friends in any communal area of the home or their individual private accommodation at any time of their choice. Discussion with a service user confirmed that his visitors are always made welcome and from previous observation it is clear that there is a good relationship between family, staff and service users living at the home. There are no restrictions on visitors unless this was evidenced in the care plan with the reasons for the decision always discussed with the individual service user and agreed with the care manager/community psychiatric nurse. Service Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 11 users would be given advice and support to enable them to maintain intimate relationships. During the course of the inspection it was observed that the routines of daily living and activities remain flexible to meet individually assessed needs within a risk assessment framework. All service users at the Fernhaven Care Home are physically able and independently mobile and as such are encouraged to undertake some small domestic tasks. During the course of the inspection, one service user was assisting with his own washing, however the success of this aim in respect of the remaining service users is often subject to the motivation of the individual. Although all bedroom accommodation has been fitted with an appropriate locking mechanism with the individual service user retaining the key to their bedroom, currently service users do no hold a key to the front door although this has been provided in the past to service users who request this. Two service users spoken with did not see this as a concern and were satisfied with the current arrangements. One service user commented ‘there is always somebody here so why would I need a key’. It was clearly evident that there is a relaxed and comfortable relationship between staff and service users with people who live at the home making positive choices about using communal areas of the home or enjoying the privacy of their individual bedroom accommodation. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 12 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): Standard 20 was assessed in part. 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: At this inspection it was noted that the medication administration record was in the main correctly recorded, however it is recommended that if a service user is away from the home at the time of administration of medication but was provided with the medication to be taken prior to leaving the home, this should be clearly indicated on the drug administration record. It was evident that as recommended in previous inspection reports, hand written medication administration records had not been double signed. This should always be undertaken and signed by the second person to ensure that the handwritten records do not contain any errors. It was also noted that the current guidance from the Royal Pharmaceutical Society of Great Britain on the control of medicines in care homes is now available to all staff that administer medication. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 13 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 The home has a satisfactory complaints system with evidence that service users feel their views are listened to and acted upon. The senior carer spoken with had a good knowledge and understanding of Adult Protection issues which protects service users from abuse, however all staff must undertake this training. EVIDENCE: The home has a satisfactory complaint policy and procedures that fulfils the requirements and recommendations of the Standard. 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. The complaints procedure is incorporated in the Statement of Purpose and Service Users Guide to inform service users and their relatives how to make a complaint should the need arise. A recently admitted service user spoken with said he was aware of the complaint procedure and that he would have no hesitation about speaking with the staff if he had a concern and felt confident that any concern would be taken seriously and acted upon. The home also has a robust policy and procedures in place for protecting service users from possible abuse. Although at previous inspections it was evidenced that the home’s procedures were based on the Lancashire County Council’s ‘No Secrets In Lancashire’ multi agency document for reporting any incident of alleged abuse, the part of the policy/procedures relating to the local protocol was missing. Through discussion with the senior carer on duty, it is understood that a number of staff have accessed the home’s policies and procedures for training purposes and may have taken the relevant page(s). Please confirm in the Action Plan that the complete document pays reference to the local protocols for reporting any incident of alleged abuse to the lead Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 14 agency and that the document also advises staff of their role in respect of this matter. Any staff that have not done so should undertake adult abuse training and it is recommended that a staff-training matrix be developed to clearly identify the training already undertaken, record when future planned training has been completed and indicate when specific training should be renewed. A variety of policies are also in place to protect service users that include, whistle blowing, restraint, and service users monies. However a number of polices and procedures evidenced were specimen policies and should be personalised to reflect the requirements of the home. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 15 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 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: Fernhaven Care Home is maintained to a good standard and is suitable for it’s stated purpose. The home is arranged over two floors. The premises are in keeping with the local community and in close proximity to local facilities and resources. Furnishings are domestic in character and provide safe and comfortable accommodation for service users accommodated. Service users spoken with were pleased with their individual bedroom accommodation and the communal space available with one service user saying that ‘it is much better than I expected’ 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. The home was clean, hygienic and free from offensive odours at the time of this inspection. The Fernhaven Care Home has a variety of policies and procedures in place for the control of infection and safe handling of waste Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 16 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. All laundry is washed at an appropriate temperature and it is understood that facilities comply with the Water Supply (Water Fittings) Regulations. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 17 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 Staff training is given high priority at The Fernhaven Care Home and further members of the care staff team are undertaking a nationally recognised training qualification in care to ensure a consistent service provided by wellqualified staff. EVIDENCE: It was evidenced that the senior carer on duty during the course of the inspection displayed the skills and abilities to provide a high quality service and along with other staff members, was a good listener and respected the individual service users needs and requirements whilst providing a structured environment. Individual discussion with service users confirmed that they felt that their privacy and dignity was always respected with one service user saying ‘the staff here are all very good and the home is well run’. Currently one member of the care staff team has achieved a National Vocational Qualification Level 2 in care and is hoping to commence Level 4 of this award in the near future. Two further members of staff are undertaking Level 2 of this award and a further member of staff who undertakes domestic duties is waiting for approval to commence a course of study in care at a local college. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 18 The new registered provider is a registered mental health nurse with many years experience of working with people that have a mental illness and is committed to undertake a NVQ 4 qualification or equivalent in management in the near future. A further member of staff also holds a mental health nursing qualification and also is very experienced in providing a service to people with a mental illness. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 19 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): Standard 42 in part Systems are in place to ensure as far as possible the health and safety of service users, staff and visitors however a number of staff should receive further training in respect of health and safety issues. EVIDENCE: As identified in the previous inspection report, staff that have not done so, should receive training in moving and handling and first aid. Although the majority of staff have completed the appointed first aid course, as recommended in Standard 42 2, a qualified first aider, who has undertaken the more advanced ‘First Aid At Work’ course should be on duty at all times. It is also recommended that all staff with responsibility for meal preperation, cooking or serving food undertake food hygiene training and consideration should be given to providing infection control training for all staff that have not received this training. As previously stated in this report, it is recommended that a staff training matrix be developed to clearly indicate the exact training undertaken by each Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 20 individual member of staff including the date the training was undertaken and the date updated training is required to ensure that the training recommendations identified in Standard 42.2 are fulfilled. Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 21 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 X 3 X 4 X 5 X 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 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X X X X 2 X Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 22 No Are there any outstanding requirements from the last 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. 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 YA20 Good Practice Recommendations If a service user is away from the home but has been provided with medication prior to leaving to take at a later time this should be recorded on the medication administration record. All hand written medication administration records should be double-checked and double signed. Please confirm that the adult abuse procedures incorporate the local protocol for reporting any alleged abuse and the role of staff in respect of this matter. Any staff that has not done so should undertake adult abuse training. It is recommended that a staff-training matrix be devised and specimen policies and procedures should be personalised to reflect the requirements of the home. The registered provider/manager should undertake an NVQ qualification or equivalent in management. Staff that have not done so should be provided with the health and safety training indicated in Standard 42.2 2 YA23 3 4 YA32 YA42 Fernhaven DS0000065618.V277356.R01.S.doc Version 5.1 Page 23 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. 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