Inspection on 04/09/06 for Fernhill Lodge Care Home

This inspection was carried out on 4th September 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fernhill Lodge Care Home 04/09/08

Fernhill Lodge Care Home 21/09/05

Fernhill Lodge Care Home 28/04/05

Fernhill Lodge Care Home 13/12/04

Fernhill Lodge Care Home 20/04/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Fernhill Lodge Care Home 5 Fernhill Road New Milton Hampshire BH25 5JZ Lead Inspector Anita Tengnah Unannounced Inspection 4th September 2006 10:00 Fernhill Lodge Care Home DS0000037561.V307305.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 Fernhill Lodge Care Home DS0000037561.V307305.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 and 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. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernhill Lodge Care Home Address 5 Fernhill Road New Milton Hampshire BH25 5JZ 01905 459800 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) Park Care Homes (No 2) Ltd To be confirmed Care Home 13 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (13), Mental disorder, excluding of places learning disability or dementia (13), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13) Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users are to be over the age of 45 years. One named Service user in the category DE Dementia can be accommodated Date of last inspection Brief Description of the Service: Fernhill Lodge is managed by Parkcare Homes No: 2, which is a trading subsidiary of Craegmoor Group Ltd, a national company providing residential and nursing care. The home is located in a residential area on the north side of New Milton, close to local amenities. Fernhill Lodge is registered to provide care and accommodation for 13 male/female residents with a learning disability and a mental disorder. Four of the residents are over the age of 65 years at the time of this visit. Accommodation is provided on two floors. The home does not have a lift and as part of the assessment process the manager ensures that only service users who are mobile are accommodated on the first floor. The current fees charged ranged between £785- £1039. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A fieldwork visit was undertaken on the 4th of September 2006. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. Staff practices were observed; service users and staff records were examined. As part of the case tracking a number of the service users and staff views were sought. There were 9 service users accommodated at the time of the visit. Four of them were in the older people category and five younger adults. This inspection therefore was carried out in conjunction with the National Minimum Standards for Care Homes for Older People and Younger Adults. The inspector had the opportunity to observe lunchtime meal being served. This was well managed and there were good interaction and service users were supported with their meals as required. The home has a manager who confirmed that she would be submitting an application to be registered with the commission for social care inspection (CSCI). What the service does well: The service users spoken with say that they are very happy living at the home. It was evident form interaction between the staff and the service users that they have developed good relationship with each other. Service users say that they are supported and treated with respect. The meals at he home is well managed and comments from service users included” the food is very good” and “I always eat everything”. The accommodation is in satisfactory state of repair, and the service users’ bedrooms are highly personalised. Staff were observed to attend to the service users in a compassionate and respectful manner. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 6 Service users have a large secure garden that they use and which is accessible to wheelchair users. 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. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The pre assessment process is good and ensures that service users’ needs could be met. EVIDENCE: Staff reported that all the service users are given information relating to the statement of purpose on enquiry. There has been one admission since the last inspection where a service user transferred from Wales. Records of assessments were available including care manager’s assessment and detailed transfer information so that an informed decision could be made prior to providing accommodation. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 9 Staff reported that service users are given the opportunity to visit the home and stay overnight as part of the assessment process. All service users are provided with a contract with the terms and condition of residency on admission. An enquiry was witnessed at the time of the inspection with regards to admitting a service user for respite care. Staff dealt with this in a professional manner and all appropriate information was given including the need for a preadmission assessment. The home does not provide intermediate care. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,14 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The health and personal care needs of the service users are well met. The service users are supported to take risks as part of daily living. EVIDENCE: A sample of two care records was seen as part of care tracking. This demonstrated that risk assessment are undertaken and care plans are put in place to show how these needs would be met. Risk assessments and care plans were detailed and contained a range of information to inform practice. These included personal care, taking risks, finance, medication and road safety. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 11 Service user spoken with said that the “care was good” and staff supported them as required. One service user told the inspector that he was attending college and is assisted by a staff member. Service users are supported to exercise autonomy and choice in relation to the activities of daily living. A service user said that he liked cooking and staff supported him. Staff reported that the home has access to an advocacy service to support the service users as appropriate. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,16,17 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 13 The meals are well managed and service users are supported to take part in varied activities to suit their needs. Service users feel that they are treated with respect and their autonomy and choices respected. EVIDENCE: Staff and service users spoken with and records seen and observations indicated that staff assist residents to become part of and participate in the local community in accordance with assessed needs and wishes. One service user spoke at length of his hobby in doing jigsaw puzzles. There was impressive framed evidence of these around the home. Some of the jigsaw puzzles he said were presents from the staff. His comment was “I have everything I need”. A large table was provided in his room to support him with his hobby and allowed him space in a bright area by the window. Another service user told the inspector of his musical interest and playing his karaoke machine. He also talked about his forthcoming holiday abroad to stay with friends. There are a variety of activities available such as trips, shopping, and events in the community. Recent outing included a visit to Marwell zoo which a number of the service users participated. Records of activities were maintained and included one to one activity with the service users. Staff reported that the service users had the opportunity to engage in adult literature such as reading and writing supported through an external visitor to the service. All four service users’ spoken with said that they are treated with respect and had their privacy respected. Staff was observed to knock prior to entering service user’s bedroom and asked another service user’s permission before showing the inspector his room. Lunchtime meal was observed on the day of the visit. Lunch appeared wholesome, nourishing and was well presented. All the service users spoken with said, “The food is very good”. A choice was offered and meal was taken in the communal dining room and the garden according to the service users choice. Staff were observed to offer support with meal in a sensitive manner. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The medication and the service users’ access to meet their healthcare needs are well managed. EVIDENCE: The service users confirmed that they have access to healthcare. Staff reported that some of the service users attended the surgery and the Dr visited on request. Staff said that the GP undertook a review of their medication/ healthcare needs every three to six months. Access to optician, dental care and chiropody was available. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 15 The home has a medication procedure that staff followed. All medication was stored securely. All staff have training in medication and staff reported that only those who have completed training are responsible for medication. There was no service user administering their medication at the time of the visit. Risk assessments were in place in support of this decision. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) 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 outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Service users have access to the complaint procedure and are confident they can use it. Staff had good understanding of adult protection procedure and the reporting process. EVIDENCE: The home has a complaint procedure that is available to the service users. Staff reported that the procedure could be made available in different formats as required such as large prints and pictorial. The 2 service users spoken with said that they are “very happy” with the care that they are receiving. They both say that they would approach the staff and named their key workers if they were not happy. The home has raised one complaint since the last inspection. This has been addressed appropriately and Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 17 involved the service user’s care manager. This has now been resolved. It was discussed with the manager that all the relevant information pertaining to any complaint should be readily accessible in the complaint log. The manager said that this would be rectified. Training in adult protection is available for staff. Through discussion with staff it was evident that the staff members had a good understanding of what constituted abuse and their responsibility in reporting any alleged abuse to the appropriate agency for the protection of the service users. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26,27,30 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Accommodation is provided in a warm and homely environment. Service users are provided with personalised rooms that meet their needs. EVIDENCE: A tour of the service was undertaken as part of the inspection and three service users’ bedrooms were seen. It was evident that the service users are encouraged to bring in items of personal belongings on admission to the home. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 19 All areas of the home was clean and in good decorative order and homely. The service users bedrooms were highly personalised and adequately furnished to meet their needs. Comment from the service users included” I have everything I need in here” and were very proud to show off their bedrooms. The bedrooms were individualised according to the needs of the service users. There are adequate communal areas at the home and service users were using various parts of the home and the garden throughout the day. The service benefits from a large well-maintained garden that is accessible and the service users were observed to make full use of this facility, where seating was also provided. All parts of the home seen was clean and there was no offensive odour when the inspector toured the building. There is a programme of refurbishment in place and staff said that the stair’s carpet was due for renewal soon. There is a laundry in place where all the service users’ laundry is undertaken internally. Staff were observed to follow infection control procedures and used aprons and gloves as appropriate. The sink in the laundry room was in need of refurbishment as part of the table was broken. Staff reported that this would be rectified, as it posed infection control risk. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30,32,36 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The home recruitment and training programme is good and ensures that the service users are protected and staff have the skills to deliver care effectively. EVIDENCE: Two staff records were seen which included copies of detailed job descriptions and application forms. All appropriate checks were undertaken and available on file to ensure that the service users are protected. It was noted that the contract and work permit related to a sister service. This was discussed with the manager, as these documents were not up to date. The manager said that these would be Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 21 rectified. Observations, discussions and available records indicated the home has an effective staff team with complementary skills and sufficient numbers to support the current needs of the service users. At the time of the inspection three care staff were on duty and a cook. The roster seen indicated this is the normal staffing level during waking hours seven days a week. The afternoon/ evening shift there are 4 staff members and one staff spends part of the shift preparing meals. The home has 1 waking and 1 sleeping staff at the time of the visit. Staff and service users’ spoken with confirmed that there was adequate staff on duty. The manager reported that a domestic staff has been recruited and was due to start soon. The home has a training programme in place and discussion with staff and record seen showed that these were adequate. Staff reported that the training “was good”. Some of the recent training included food hygiene, first aid, adult protection and challenging behaviour. Four staff members are near completion in NVQ level 2 and 4 staff have completed NVQ 3. A requirement was made following the last visit for a structured supervision programme to be put in place. Record of two staff seen showed that they had supervision in January 06 and there were no further records available. This was discussed with the manager who said this would be rectified. The manager is aware that all staff must have a minimum of 6 supervisions a year and records of these should be maintained. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. The home has an effective quality assurance and monitoring systems in place to ensure the home is run in the best interest of residents. The health and safety of residents and staff is promoted. Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has a manager and discussion with staff and service users showed that the home is well managed and views of the service users are sought. The manager is undertaking her NVQ 4 in care and also the Registered Manager’s Award. The manager undertakes regular updates to maintain her skills and has completed the assessor’s course. Application for the manager to be registered with the commission was discussed. The manager confirmed that this was in hand and will be submitted soon. Staff reported that the service users’ views are sought with 1-1 meeting on a monthly basis. As part of the development of the service, a conference was held in July 06 in conjunction with the other services in the company. Staff reported that this was successful and they are planning to set up a service users’ community forum on a quarterly basis. The requirements following the fire safety officer’s visit have been met. A review of fire exit signage on the first floor was discussed and advice will be sought from the fire safety officer. It was noted that the communal bathrooms/ toilets were not marked and may be confused with the service users’ bedrooms. The person in charge said that this would be rectified and appropriate sign on doors would be fitted. All records were maintained safely and staff were observed to follow infection control procedures. Substances that are hazardous to health were locked appropriately and ensured that service users’ safety is safeguarded. COSHH sheets were maintained for all substances used. Fernhill Lodge Care Home DS0000037561.V307305.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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 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 X 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 3 39 3 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fernhill Lodge Care Home Score X 3 3 X DS0000037561.V307305.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA36 Regulation 18 (2) Requirement The manager must ensure that all staff receive formal supervision as part of their practice. Timescale for action 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fernhill Lodge Care Home DS0000037561.V307305.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Fernhill Lodge Care Home DS0000037561.V307305.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. 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