Inspection on 24/09/07 for Fernica

This inspection was carried out on 24th September 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fernica 30/08/06

Fernica 23/03/06

Fernica 20/04/05

Fernica 04/10/04

Fernica 06/04/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Fernica Fernica 18-20 Kings Road Prestwich Manchester M25 0LE Lead Inspector Lucy Burgess Unannounced Inspection 24th September 2007 09:30 Fernica DS0000044739.V345851.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 Fernica DS0000044739.V345851.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. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernica Address Fernica 18-20 Kings Road Prestwich Manchester M25 0LE 0161 773 6603 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) Mrs Miriam Elizabeth Laventiz Miss Marguerite Clark Miss Marguerite Clark Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 14 service users, to include: Up to 14 service users in the category of MD (Mental Disorder under 65 years of age). The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 30th August 2006 2. Date of last inspection Brief Description of the Service: Fernica is a small care home providing accommodation and support for up to 14 people with mental health needs. The present range of fees are £355.00 to £377.00 per week, however may vary dependent on the assessed needs of individuals. The home is located within the Prestwich area and is close to all local facilities. Public transport may be easily accessed for Bury, Prestwich Village and Manchester City Centre. The home is made up of two semi-detached houses, which have been converted into one property. Accommodation is provided on three levels. There is no lift facility. The home is a family run home, offering accommodation to adults with mental health needs and is staffed on a 24-hour basis. The home caters for both short and long stay service users. All bedrooms are single however no en-suite facilities are provided. Of the bedrooms, two do not meet the spatial requirements as stated within the National Minimum Standards. This information has been detailed within the homes Statement of Purpose. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home. The inspection was carried out over one day, between the hours of 9.30am to 3.45pm. During the visit time was spent looking at paperwork and the environment as well as observing staff interactions with residents. The inspector also spoke with residents, staff and the manager. Before the inspection, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home sees the service they provide the same way that we see the service. Feedback was given to the manager about how the form could be developed in relation to the level of information provided. Feedback surveys were also sent to service users and staff. The inspector received 9 completed surveys from service users, relatives and health care professionals. Comments have been included in the report. The home is registered to provide accommodation for 14 people. There were no vacancies. All the key standards were looked at during this inspection visit as well as the action identified during the last visit. What the service does well: The home continues to provide a stable living environment for residents. The staff team is small and have worked together for some time. Each have a good understanding of the individual needs of residents, which has contributed to the health and well-being of residents remaining stable. Additional support continues to be provided from the local mental health teams so that residents are supported in maintaining their mental health and wellbeing. The inspector spent time speaking with 6 residents, discussing things, which have happened since the last visit. Four residents also returned their feedback survey. Residents expressed that they were happy living at the home and that some of them had been together for many years. Residents said they enjoyed doing things together as well following their own interests. Some of the comments received included; ‘I like living at Fernica, Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 6 the other residents and the food is okay’, ‘I make my own decisions’, ‘the staff have explained the complaints procedure and that there is a book’, ‘I find the home is always clean and tidy’ and ‘I’m happy and comfortable living here’. Other surveys were received from 2 health care professionals and 3 relatives. They expressed, ‘the home provides an individualised care package with the emphasis on community contact and interaction’, ‘ individualised, balanced between patients needs and their mental health’, ‘they provide a friendly atmosphere’, ‘they always encourage visits or contact via the phone’, ‘the manager and the staff look after them wonderfully’, ‘they provide residents with a decent quality of life’ and ‘they generally cater very well for my son, allowing him to follow his own interests’. What has improved since the last inspection? What they could do better: Information is provided to the home about any areas of potential risk, however a plan of action needs to be provided for staff to follow should concerns arise. This will ensure that the resident receives the necessary support as well as making that both they and others within the home are safe. Whilst the manager has developed a supervision system, meetings have not been held as often as needed and records were not available for all members of the team. The manager needs to make sure that all staff, care and domestic staff are offered the guidance and support needed in carrying out their role and responsibilities. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 7 The manager is to provide a training matrix showing what courses staff have completed as well as what is still needed. The manager must ensure that a suitable qualified training provider provides all training. One of the areas the home should explore is an annual report based on the feedback from service users and other parties about the quality of service provided and how this will inform future plans. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 8 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 Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are planned and include the sharing of information as well as visits taking place. This gives prospective residents and staff the opportunity to make an informed decision about whether they are able to fully meet their needs. EVIDENCE: Assessment information was looked at for two new residents, who had moved into the home following the last inspection. One resident had moved in on a permanent basis whilst the second was receiving respite. Individuals are referred to the home from the mental health team due to changes in the current living arrangements or as part of their resettlement following discharge from hospital. As part of the resettlement programme prospective residents have the opportunity to visit the home, stay for a meal and an over night stay. This would be planned over a period of time, which suited the resident and provides individuals with the opportunity to decide whether they would like to live at Fernica. Existing and prospective residents also have an opportunity to spend time together and get to know each other. Visits to the home also provide staff with the opportunity to look at the persons assessed needs and decide if Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 10 these can be met at the home. Following the last inspection, the manager and staff team decided that the placement for one individual who had been visiting the home was unsuitable and that their needs could not be met. Both of the care files looked at contained information, which had been provided by the relevant local/funding authority. Information included an assessment and risk-screening tool. The individual receiving respite also had a short term plan, which identified what action was required to address their long-term needs both in relation to care and support and accommodation. The home also completes an assessment form, which is held on file. Collectively this information is then used to inform the care plan. Placements are then reviewed as part of the hospital discharge and/or placement agreement following the initial 6 to 12 week period. Evidence of these meetings is held on file. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans identify the support needs of residents however need to show how staff manage potential areas of risk, ensuring residents and others are protected from harm. EVIDENCE: Care plans and assessments are held for each of the residents. Files were looked at for 3 residents. One who had recently moved in, one on respite and another person who was currently in hospital. Information was orderly and included an individual plan, discharge plan reviews (CPA) minutes, health appointment and outcomes, financial information, diary notes, weights and a contract. Plans had been reviewed internally on an annual basis and again within the formal reviews held with health care professionals. Areas covered within the plans explored a variety of activities, such as, mental health, hygiene, finances, smoking, medication, routines and support on a 1-2Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 12 1. This varied dependant on identified support needs. It was noted that the section on routines was a general plan and did not reflect individual routines. These should be amended to reflect which each person does each week both in and away from the home. It was also found that where there had been changes in health or behaviour an entry had been made within the diaries, however daily entries were not being made. This should be done to provide effective monitoring. Risk assessment should also be updated to reflect the changing needs and identify a management plan with regards to how support should be provided by staff to assist in minimising any risk to the resident and others within the home. Health care records were detailed and evidenced outcomes and any further treatment required. Financial records for personal allowance were also well managed and could be easily audited. Where restrictions were in place with regards to cigarettes and money, agreements with residents had been recorded on the care plans and signed by both parties. It was further evident within the plans, review notes and finance records that residents had been on the activities involved and had signed where necessary. Residents appeared happy and settled and enjoyed a good rapport with each other. They made the inspector very welcome and were happy to chat. Comments received from others who visit the home included, ‘the manager and the staff look after the residents wonderfully’, ‘they provide residents with a decent quality of life’, ‘all his needs and dignity are looked after’ and ‘we’re always kept informed’. In response to what the home does well, one relative said ‘it’s the personal time and care they take with residents’. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to follow lifestyles of their choosing both in and away from the home so that they maintain their independence as well as learning and developing new skills. EVIDENCE: Residents continue to follow routines and activities of their choosing both in and away from the home. Whilst some residents have regular planned activities other enjoy a more relaxed routine. Residents rise and retire as they choose. This was observed during the inspection. The majority of residents have a travel pass allowing them easy access to public transport between Bury and Manchester. The home is also situated close to all amenities including shops, take-away, post office, church and synagogue. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 14 None of the residents have full employment although several do still attend the therapeutic employment scheme. Other activities include attending a local drop-in, visiting local shops and café, library, music lessons as well as tasks within the home or relaxing watching the television or videos and listening to music. Residents also had the opportunity to visit Botany Bay and Skipton Castle during the summer. Those spoken with enjoyed the trips and some have requested to return to Botany Bay before Christmas. This is being arranged. The manager also explained that arrangements have been made for everyone to go out for the Christmas party. Each year the group visit a pub/restaurant in Blackburn for a meal. Approximately half of the residents continue to have access to staff support provided from their CPN’s, social worker or Creative Support workers. This involves individuals being supported in a 1-2-1 sessions supporting residents in accessing community facilities as well as developing more practical skills. In relation to religious needs. Those residents wishing to attend church or synagogue are encouraged to so and support would be provided within the home should individual residents wish to follow some of the festivals. Residents also maintain contact with family and friends. One relative expressed, ‘they always encourage visits or contact via the phone’. Records show where relatives have visited or when residents have gone out. One resident who had recently celebrated a birthday, talked about enjoying a meal out with his friend. Staff provide additional support for those individuals who have been identified for rehab programme. Two residents are currently on the programme and are encouraged for example to plan a meal. This would include planning the meal, doing the shopping, preparing and cooking the food. This enables them to develop practical skills and independence for when they are able to move to alternative accommodation. Menus are in place offering a variety of meals with alternative options and special diets are also being catered for where necessary. Usually a lighter lunch is served with a cooked meal in the evenings. Some individuals cater for themselves if away from the home during the day. The home also maintains health care records, which includes the monitoring of weight. Action would be taken with referrals to the dietician if a need were identified. Some of the comments received from residents and relatives included; ‘I like living at Fernica, the other residents and the food is okay’, ‘I make my own decisions’, ‘they provide a friendly atmosphere’, and ‘they generally cater very well for my son, allowing him to follow his own interests’. Fernica DS0000044739.V345851.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to offer consistent support to meet the individual needs of residents ensuring that their health and well-being is maintained. EVIDENCE: Residents have access to health and social care professional as and when they are needed. These include GP’s, psychiatrists, dentists, dietician, nurse clinics, social workers and consultants. A clear record is made of all appointments and support is provided. Both staff at the home and the mental health teams ensure the well-being of residents is maintained by closely monitoring their mental health. Where concerns are identified the appropriate action is taken. This was observed during the inspection as one resident was causing some concern due to deteriorating health. An emergency appointment was arranged with the psychiatrist so that support could be provided to help manage the concerns as well as minimise the risk to the resident and others within the home. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 16 Formal reviews with social workers and mental health teams are still undertaken to look at the on-going support needs of residents ensuring the stability of the their mental health and well-being. Minutes are recorded and held on file. These meetings are in line with the discharge plans agreed for each individual. As part of these agreements some residents receive 1-2-1 input from the mental health support teams, which includes supporting individuals to access places within the community, developing new skills as well as increasing the confidence and independence in carrying out tasks. These take place as agreed within individual plans and further help to monitor the stability of the resident’s health and behaviour. Generally each of the residents are able to manage their own personal care needs and this is encouraged so that individuals maintain some level of independence. However where necessary residents are prompted or supported by the staff to ensure they maintain their own care and general well-being. Where support is provided this has been detailed within the care plan. A bath chair has been provided in one of the bathrooms to offer further assistance to residents and staff. The medication system was examined. This was found to be safe and records had been completed in full. Records continue to be made of all items delivered and returned to the supplying pharmacist. The supplying pharmacist, BOOTS, had carried out a recent audit in August 2007. This was found to be satisfactory and the inspector saw a copy of the report. Some residents had medication, which had not been supplied by BOOTS. Details of the medication provided had been clearly hand written on an administration record and had been signed by 2 members of staff to ensure that the information recorded was correct. All administration sheets were completed in full and where medication had not bee given the relevant code had been entered. Residents’ medication continues to be monitored and reviewed on a regular basis by health professionals ensuring the stability of their mental health. At present none of the residents in receipt of medication self-administer, however one resident was being supported in the office to administer her own medication whilst being observed by staff. Feedback was also received from health and social care professionals who also provide support to the home. Comments included, ‘the home provides an individualised care package with the emphasis on community contact and interaction’ and ‘individualised, balanced between patients needs and their mental health’. Fernica DS0000044739.V345851.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a clear, understandable complaints system in place, which ensured that residents’ views were listened to and acted upon by a staff team who had received adult protection training. EVIDENCE: As identified at the last inspection, the home has a complaints procedure, which is clearly displayed and accessible to each of the residents and visitors. Information has been updated to include the new contact details for CSCI. Residents also have individual copies of the procedure in their service user guide. Since the last site visit there have been no issues raised with either CSCI or the home. Comments made by residents within the surveys confirmed that they were aware of what to do if they had any concerns. One resident expressed ‘the staff have explained the complaints procedure and that there is a book’, and resident said she was aware that there was a copy of the procedure and contact numbers on the notice board. In relation to protection, relevant policies and procedures are held by the home. All the staff have now received training in adult protection as required following the last visit. The inspector also spoke with the manager about how residents managed their finances. Some individuals are subject to appointee with the local Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 18 authority, one resident has support from an appointed solicitor and the remaining are supported by the home. The manager holds detailed records, which are signed by the residents following each transaction. Receipts are also held for any purchases made so that information can be easily audited. Personal allowances are held by the home and agreements made with regards to how this is to be managed. A number of residents are on a budget plan, which supports them in managing their money throughout the week. A random check was carried out and was found to be correct. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On-going improvements have been made within the home, which has enhanced its appearance providing a clean, comfortable home for residents. EVIDENCE: Fernica is a large detached property, originally two houses, which have been made into one. Accommodation is provided on 3 floors and comprises of 2 lounges, dining room, sitting area and kitchen. There are 14 single bedrooms and 4 full bathrooms. The majority of residents are able to manage their own personal care needs, however some residents now need some level of support due to their age and physical abilities. Assisted bathing facilities are provided on the ground floor enabling further support to be provided for residents in managing their personal care needs. Whilst the manager accepts that these needs can be managed within the home she is also aware that they do not have the equipment, space of staffing to cater for any increased physical support needs. Should this arise a review of care would take place to explore what could be provided. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 20 A separate laundry room is also available on the 1st floor and an office, with sleep-in facilities is also available for staff on the lower floor. One of the lounges was used as the designated smoking area, however due to the new laws coming into effect, alternative arrangements had to be made. Residents and staff have agreed that smoking is only permitted outside of the home. The manager said that arrangements are to be made for a canopy to be fitted in the garden offering some shelter. Residents who smoke were asked how they felt about the changes. One resident said that he ‘didn’t mind’ and that ‘it had helped him to cut down and he felt better for it’. Others generally felt the same. In relation to maintenance, the manager keeps a record of all work identified and carried out within the home. Since the last visit work has included, new windows, new beds, redecoration of the basement hall and stairs and kitchen, new flooring to the basement and kitchen, externally painted and new taps in kitchen and bathrooms. Further work is planned within the lounge areas. With regards to domestic tasks, the home employs a housekeeper who takes responsibility for the majority of tasks however residents are encouraged to keep their rooms clean and tidy. Where additional support is required this is provided. The home has access to a regular handyman who will carry out general repairs, redecoration and some of the safety checks. Records are maintained in relation to fire safety and up to date COSHH assessments are in place. On the day of the visit the home was found to be clean, warm and tidy. Feedback from residents and visitors about the cleanliness of the home was positive. Comments included, ‘I find the home is always clean and tidy’ and ‘I’m happy and comfortable living here’. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A consistent staff team who have been appropriately recruited support the residents. Information on staff training and supervision is to be developed to show staff have the knowledge and skills to meet the needs of residents. EVIDENCE: As already identified staffing at the home has remained consistent. The team comprises of the 2 owners, one of which is the registered manager, 2 regular staff and a bank worker. There is also a housekeeper. The home has access to a handyman however he is not directly employed by the home. Staffing rotas were looked at. Generally there are 2 support staff working each day with single cover in the evenings and a sleep-in each night. The manager is very much ‘hands on’ and undertakes 2/3 sleep-ins each week and does have the opportunity for administration work. Several residents also receive 1-2-1 support from external providers such as Creative Support or via the local mental health teams. Each have a specified number of hours each week and is used for community activities, learning new Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 22 skills or attending appointments. A number of the residents are male and do access the community independently of staff. As for the staff team, communication between each other is on a daily basis. Handovers are carried out when starting shifts and periodic team meetings are also held, ensuring that everyone is aware of events taking place within the home. In relation to recruitment no new staff have been employed for some time. An outstanding check not seen at the last inspection was examined and found to be in order. The manager is aware of her responsibility in ensuring all relevant information is gathered prior to commencing new staff. With regard to training, adult protection training has been undertaken by those identified at the last inspection. Each member of the team has commenced a distance learning course in food hygiene and 2 members of the team have completed a first aid course. NVQ training has also been offered, one member of the team has completed level 2 and is currently doing level 3, another member of the team has already achieved level 3, the manager has now completed level 4 and the Registered Managers Award and the second owner is a registered mental health nurse. The home is not a member of the Bury Training Partnership Group. This is available to all Providers within the Borough offering support and advice as well as providing training in line with Skills for Care. At the last inspection the manager was asked to explore other training needs of staff and refresher courses. A skills audit should be undertaken outlining what training staff have completed and any future plans along with timescales for completion. Information should also be accessed with regards to the ‘Skills for Care Induction and Foundation training’ so that should any new staff be employed by the home the appropriate training and support can be provided. The home already has copies of the GSCC code of practice booklet. The manager was also asked to develop a system of formally supervising staff. Whilst this has been undertaken this has not been for each member of the team, including bank staff and the housekeeper and not in line with the standard of a minimum of 6 times per year. This area should be explored. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is consistent and involves consulting with residents about their plans for the home. Responsibilities in relation to health and safety are also addressed. EVIDENCE: Fernica is a family owned home and is ran by two sisters who also directly work at the home, one of which is the Registered Manager. The manager is a qualified nurse and had worked at the home for many years prior to becoming the owner/provider. She has now completed her NVQ level 4/Registered Managers Award. Copies of her certificates are to be forwarded to CSCI. The other owner is also a registered nurse with many years of experience working with people with mental health problems. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 24 Discussion was held with the manager about the new inspection process. As already stated the manager had completed and submitted the AQAA prior to the inspection taking place. The manager was advised about what other information could be provided within the assessment to evidence the work being carried out by the home. The manager was also asked if the National Minimum Data Set information had been completed. This has not as yet. The manager was asked to provide the registration details to the CSCI once this has been completed. In relation to quality monitoring, the home does liaise closely with residents both informally day to day and within the periodic residents meetings. Families are also contacted where necessary and kept informed. Further feedback is also sought from residents and families through the formal review meetings, which are held with social workers and mental health professionals. Staff feedback is also sought from the staff during the periodic team meetings. The Manager also previously given out questionnaires about the service to residents however this area has not been explored to include other parties involved with the home, such as family/relatives, social workers, CPN’s etc. The manager needs to look at formalising a way of gathering information from people involved with the service, which can be summarised into a report, which includes an action plan for future improvement. A copy of the report should be supplied to the CSCI. A copy should also be available to residents and others, so that they know that their comments are being noted and acted upon, where necessary. With regards to health and safety, the handyman continues to carry out regular checks within the home. This includes fire safety, water and small appliances. Further checks are carried out ensuring the safety of staff and residents and certificates are held within the home. These included the 5 year electrical check, gas safety, fire alarm, emergency lighting, smoke detectors and the bath chair. The home had also had a visit from the Food Safety inspector in February 2007. Minor action was identified. As already stated the COSHH assessments had been reviewed and up dated. The inspector was aware that incidents had occurred within the home, information had been recorded appropriately and copies of Regulation 37 reports had been forwarded to CSCI. Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 25 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 3 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 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 Requirement Where areas of potential risk have been identified or due to changing health needs a risk assessment needs to be developed clearly showing how staff should respond ensuring the safety of those living at the home. The manager should development a training matrix that which identifies training undertaken by staff and further areas of development, which meets the needs of those living at the home. A copy of the matrix should be forwarded to CSCI. All staff working within the home should receive supervision a minimum of 6 times per year and discussion should recorded and held on file. Information should address the needs of the home and any areas of training and development. (30.11.06) Timescale for action 30/11/07 2. YA35 18 30/11/07 3. YA36 18 30/11/07 Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 27 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 YA7 Good Practice Recommendations Care plans in relation to activities and routines should provide specific information about residents showing what things they are involved in on regular basis. A record should be made in the daily diaries on a daily basis to show that the health and well-being of residents is being monitored. The manager should forward copies of her NVQ/RMA certificates to CSCI. That consideration is given to the development of a quality assurance system and a report in relation to the findings. 2. YA7 3. 4. YA37 YA39 Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fernica DS0000044739.V345851.R01.S.doc Version 5.2 Page 29 - 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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