Inspection on 19/09/07 for Fernlea

This inspection was carried out on 19th September 2007.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fernlea 16/09/08

Fernlea 06/03/07

Fernlea 11/07/06

Fernlea 14/02/06

Fernlea 17/10/05

Fernlea 31/01/05

Fernlea 13/07/04

Fernlea 15/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Fernlea 59 Fort Ann Road Soothill Batley West Yorkshire WF17 6LS Lead Inspector Cathy Howarth Key Unannounced Inspection 19 September and 3 October 2007 10:00a Fernlea DS0000001081.V343166.R02.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 Fernlea DS0000001081.V343166.R02.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. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernlea Address 59 Fort Ann Road Soothill Batley West Yorkshire WF17 6LS 01924 470176 F/P 01924 470176 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) www.st-annes.org.uk St Anne’s Community Services Mrs Sarah Grogan-Evans Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Seven service users with learning disabilities and four who also have physical disabilities. To provide accommodation and care for one named service user over 65 years 6th March 2007 Date of last inspection Brief Description of the Service: Fernlea is a care home registered to provide nursing care and accommodation for three adults with learning disabilities and four adults with learning and physical disabilities. The registration category also includes one person who is over 65 years of age. St Anne’s Community Services, a charitable organisation, operates the home. The home is located in a residential area close to the centre of Batley. There are shops, a post office and community facilities within 5 minutes’ drive of the home. The property is a brick built, detached bungalow which was purpose built for use as a care home. Internally, the home is separated into two discrete units, one providing care and accommodation to adults with severe learning disabilities (red side), and the other providing care and accommodation to adults with physical and learning disabilities (blue side). All the service users have complex needs. The property has small, secure sheltered gardens on either side of the home and parking space on a drive. Internally, there is a central area where there is staff sleeping in accommodation, the laundry, sluice room and a storeroom. Accommodation on the red side comprises three single bedrooms, a lounge, kitchen/diner, bathroom, shower room and an office. Accommodation on the blue side comprises four single bedrooms with wash hand basins, kitchen/diner, lounge and a conservatory that is also used as a multi-sensory room, shower room and an adapted bathroom. The range of fees charged for this service is £208.20 to £459.56 per week. This does not include the nursing component, which is paid directly by health. The pre-inspection questionnaire states that additional charges are made for the following: activities, hairdressing, toiletries/clothing, accessories, newspapers and transport (charged at £72 per month each). Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 5 The service provider ensures that information about the service is available to prospective service users and the people currently living there by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out using information provided by the manager before the visit. Surveys were sent to users, their relatives and health and social care professionals involved at the home. Surveys were returned from all six people living at Fernlea, who completed the questionnaires with support from staff. One relative and one social care professional also responded. The inspector made an unannounced visit on the first day of this inspection, which lasted seven hours. The follow up visit was planned in advance in order to see some written information which was locked up on the first visit. What the service does well: Service users’ needs are assessed before they move into the home so that staff are aware of individuals’ needs and aspirations. Most people’s needs and identified risks are reflected in their individual plans and people are supported to take some reasonable risks and make some choices. People’s lifestyles at Fernlea are improving. People living at Fernlea receive good personal care in a way they prefer. The management of healthcare is generally good but some improvements are needed. There is a strong commitment to safeguarding the welfare of people using the service. People live in a homely and comfortable environment, which is kept clean. Staff recruitment, induction, training and development opportunities are good but vacancies need to be filled in order to provide people living at Fernlea with consistent carers. The home is managed reasonably well in the best interests of people living there. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fernlea DS0000001081.V343166.R02.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 Fernlea DS0000001081.V343166.R02.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. People using the service experience good quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. Service users’ needs are assessed before they move into the home so that staff are aware of individuals’ needs and aspirations. EVIDENCE: Records relating to three individuals were examined. All contained evidence that pre-admission assessments had been conducted. There have been no new admissions to the home since the last inspection. One social care professional who returned a survey commented that they felt the assessment process in future should include a careful consideration of compatibility issues before coming to live at Fernlea to avoid some of the problems that have been experienced in recent times with physical intimidation and aggression within the home. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience good quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. Most people’s needs and identified risks are reflected in their individual plans and people are supported to take some reasonable risks and make some choices. Some improvement in monitoring and review is needed. EVIDENCE: Three individual plans were examined. Each provides clear information to staff about how to meet individual needs and is developed using information following a person centred planning meeting. Each service user has a named nurse and key worker who take responsibility for the development and review of the care plans. For one person who has been seriously ill, there were very detailed notes about meeting his changed nursing needs. For the other two people whose files were examined, there was detailed guidance regarding their specific needs, especially in relation to their behaviour and communication Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 11 needs. Evidence of how they are supported to make choices was also seen. This was positive. There was evidence that the needs are reviewed through the person centred planning process. There was also evidence on two files that reviews involve the users themselves. For two people, there were fairly detailed daily notes, which gave a clear picture of how goals were being met. On the other file, it was seen that there was no evidence of monitoring of goals and little preparation for a review that was due in September but had not been arranged at the time of this visit. For this person, the daily records focused almost exclusively in their clinical needs. This may be due to the particular needs of that person following a recent illness; however there should be a more rounded view to help ensure staff focus on wider quality of life needs as well as medical needs. The goals for this person need to be reviewed as a matter of urgency in order to take account of his needs due to his changed circumstances. One relative who responded to the inspector’s survey indicated that they were confident that individual needs were met but said they would prefer more consultation around reviews so that they could be fixed at convenient times to allow them to attend. A social care professional commented: “they have a good understanding of the resident’s needs and wishes. They are very committed to maximising his potential and opportunities.” All three files seen had good risk assessments in place for a variety of activities and potential hazards both in and outside the home. The process for this appears to be well embedded in the practice of the home. This helps to maximise users’ opportunities and experiences. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People using the service experience adequate quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. People’s lifestyles at Fernlea are improving. EVIDENCE: Of the three case files examined it was seen that, for two people, there were good opportunities for them to go out and make clear choices about their lifestyles. However, these people receive extra support from an external agency in order for this to occur. For the other person, their opportunities have been severely limited by recent illness. This person needs support in order to improve their life chances and to make sure that, despite their limitations, they can still enjoy a good quality of life. Unfortunately, as detailed above, the planning for this has been limited and staff have been over-focused on medical needs. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 13 Six users of the service returned surveys. Four reported that they could make choices about how they spent their day but two said they could not. This is an area that that has been of concern at previous inspections. Recruiting drivers has been a problem in the past and this continues to make going out difficult for those individuals who cannot easily use public transport. On the first day of this inspection, it was observed that most people were out doing some activity, including one person who went shopping with a member of staff. At the last inspection there was considerable concern about the level of activity available to people living at Fernlea. The manager was able to show on this visit that considerable efforts have been made to improve this and she has set up systems to record what is being done with people. She has changed the emphasis to doing everyday things such as shopping and going for walks and getting people out and about the local area. For most people, this has led to an improvement in their activities but the new approach still needs to be firmly embedded into practice within the staff team. One relative also indicated that they felt that people did not always get enough staff attention, as they suggested that a housekeeper post would free staff up to spend more time with people living at the home. This relative also indicated that the high turnover of staff and use of agency staff affects people’s opportunities. Evidence in service user records and completed surveys from relatives indicates that good support is offered to service users to maintain contact with their families. Menus were seen and showed that people had a good range of foods offered. Also, the home tries to ensure that everyone receives the recommended ‘five a day’ of fruit and vegetables. Some people were observed helping themselves to snacks and making drinks with support from staff. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 14 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): People using the service experience adequate quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. People living at Fernlea receive good personal care in a way they prefer and the management of healthcare is generally good but some improvements are needed in the management of medication and in tracking of routine health screening. EVIDENCE: Individual plans show how people using the service like to be supported. These also detail their emotional and physical needs that are identified. Ok health checks were found but on one of these the quality of the information was poor. The other two seen were of a good standard. One person has been seriously ill and now has a permanent physical disability that requires intensive support. The guidance for staff, in relation to this in order to meet his needs, is excellent. The manager has sought information from other health professionals to support keeping this person living at Fernlea and is a good example of the staff achieving a positive outcome. The person in Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 15 question is becoming stronger and returning to himself as a result of this intensive support. The home operates to standard medication practices and policies. However, medication management was not as good as it should be. For example, one person’s health assessment indicated that he might experience pain due to his particular diagnosed syndrome. However ‘as required’ pain relief medication was not available as apparently staff thought it related to having had teeth extracted some time ago. Therefore, no replacement stocks had been ordered for some time. The reasons for ‘as required’ medicines should be clearly documented. Another person also had no stock of a sedative medicine. This had been used rarely but was prescribed by the consultant and therefore stocks should have been available should it be required. A requirement has been made in respect of this. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 16 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, 23 People using the service experience good quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. There is a strong commitment to safeguarding the welfare of people using the service. EVIDENCE: A satisfactory complaints procedure is in place. The pre-inspection information indicated that no complaints have been received at this home in the last twelve months and systems are in place for recording complaints. In addition to this, the manager sends out her own surveys to people and their relatives or social workers to get their views about the service and the manager said this had informed some practice, eg. one parent had said that, because her son’s bed was always stripped when she came to take him home, it affected how she viewed his room and didn’t feel it was homely. Since the last inspection in March, the manager and staff have made considerable efforts to ensure the safety of people living at Fernlea. Previously, there was some concern about the level of aggression especially between two people living there. These incidents have markedly reduced, as staff have adhered to a tight protocol in terms of managing shifts in order to keep people safe. This has been a successful multidisciplinary approach involving a psychologist and other workers associated with the individuals. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 17 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, 30 People using the service experience good quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. People live in a homely and comfortable environment, which is kept clean. EVIDENCE: The home is purpose built and divided into two distinct areas catering for people with different needs entirely. Overall, it was found on this visit that the environment was generally in good order both in terms of maintenance and décor. There were still some outstanding issues, however, from the last inspection, such as the poor state of the flooring in the red kitchen. This should be addressed as a matter of urgency as it is a health risk due to the poor seals meaning that it can harbour sources of infection. It was seen that communal areas were generally decorated and furnished in a homely fashion. On the blue side, there are difficulties because of the minimal space and the need for suitable equipment for people with complex physical Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 18 needs. The conservatory is fitted with some multi-sensory equipment, which staff said is enjoyed by some individuals who live on that side of the building. The home was found to be clean and fresh on the day of this visit and people using the service, in response to the surveys, said that this is always the case. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 19 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 and 35 People using the service experience adequate quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. Staff recruitment, induction, training and development opportunities are good but vacancies need to be filled in order to provide people living at Fernlea with consistent carers. EVIDENCE: Fernlea provides nursing care for the people who live there and so there is always a qualified nurse on duty. Support staff are well trained, having had a thorough 5-day induction, which covers basics needed to be able to provide care for the people living there. St. Anne’s has a monthly rolling programme of induction training so staff do not have to wait long to be able to go on the induction training. NVQ training is not as well developed as would be desirable. Support staff do have the opportunity to complete LDAF (Learning Disability Framework) training and the manager hopes that staff will go on to do NVQ level 2 or 3 training, both are available . Two staff are currently doing this. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 20 Examination of staff rotas and discussion with the manager confirmed that the home continues to use a fair amount of agency cover. The impact of this is minimised as far as possible by using known people on a regular basis but it is difficult to maintain the consistency of care that the people living at Fernlea require to keep them safe and well with such a high level of bank and agency workers covering the rota. One relative expressed concern about this too, saying that staff turnover appears to be high and vacancies have to be filled with bank and agency staff. A suggestion made by one relative was that the home employs a housekeeper to do the cooking and cleaning and so free staff up to spend more time with the people living there. The home has several vacancies at the moment that need to be filled as a matter of urgency and extra funding for one person is being sought to increase their quality of life through greater opportunities. This would increase the establishment and reduce the reliance on agency staff. Since the last inspection, staff have had training around physical intervention and particularly in relation to the individuals they support at Fernlea. This is a positive move. During the inspection, records relating to staff recruitment were examined. The main records are held at St Anne’s head office but the home has a checklist of what has been received for each person. The inspector also saw records relating to agency staff, as supplied by the agencies used. These showed that agency staff are also checked and receive a basic induction into the running of the home. Staff receive regular supervision and annual appraisals. Records relating to staff were not available on the first visit to this service, as required by the Care Homes Regulations 2001. There should be arrangements in place to ensure that they can be made available for inspection when the manager is not there. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 21 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, 42 People using the service experience adequate quality outcomes in this area. This judgement has been made using a range of available evidence including a visit to this service. The home is managed reasonably well in the best interests of people living there but some improvements are needed in fire safety. EVIDENCE: The manager of the home is a qualified nurse and experienced manager. Feedback from staff is that she is a supportive manager and works in the interests of people living at Fernlea. One relative also said: “the manager is excellent.” Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 22 The manager sends out satisfaction questionnaires annually to relatives and others involved in the care of people living at Fernlea. She acts on any suggestions made or comments received as far as possible. The home has a ‘Team Plan’, which details areas for improvement for the year identified by the staff team. This was a positive but it would be of more benefit if the goals were linked to actions and measurable outcomes so that staff could feel that they were making progress. For example, one goal was to promote independence for people living there. Whilst this is a laudable goal, it lacks substance about how exactly that would be achieved. It would be difficult, therefore, for staff to feel that they were making progress, as it would be likely the goal would be the same for next year. This runs the risk of staff feeling demoralised by lack of progress and makes it difficult for the manager to demonstrate improvements in the service. The inspector found that Health and Safety matters were generally managed well. The home received a four star award from environmental health this year following an inspection of the kitchen. Routine maintenance tests and equipment tests were found to be up to date. Staff carry out regular water temperature tests which are recommended to ensure that people are not taking baths in excessively hot baths and being scalded. It was found at the last inspection, however, that on the blue side water temperatures were too low. On examination of the records it seems that this is still the case at times but staff have not been taking action when they have found this during tests. Some recordings showed temperatures to be as low as 38°C. This is too low for a comfortable and relaxing bath for the majority of people. Staff need to be vigilant and take action when they find temperatures that are too high or too low rather than simply recording them. Fire safety at the home is adequate. There are regular tests of equipment and warning systems. However, there were some areas that need to be addressed. Namely, fire drills need to be held frequently enough for all staff to participate twice a year, including night staff. Also, a door closure had been removed from one door. This constitutes a potential risk and it was not clear why it had been removed. If it is necessary for the door to be without a closure, then this must be directly addressed in the home’s fire risk assessment. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) Requirement Timescale for action 31/10/07 2 YA20 13 (2) 3 YA42 23 (4) The individual whose needs have changed significantly must have a review of their needs to address their overall quality of life. There must be adequate stocks 01/10/07 of prescribed medication to meet any needs of people living at the home. Fire safety must be improved by: 31/10/07 The bedroom door with no automatic closure should have it replaced or it should be clear how the risk is to be managed. 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 YA19 Good Practice Recommendations To ensure that service users’ healthcare needs are met, routine health checks should be kept up to date. OK health checks should be reviewed where necessary and completed in full. DS0000001081.V343166.R02.S.doc Version 5.2 Page 25 Fernlea 2 3 4 5 YA30 YA32 YA33 YA42 In order to keep the home clean and hygienic, the floor covering in the kitchen on the red side should be replaced. To ensure that service users are supported by suitably qualified staff, 50 of care staff should have at least an NVQ level two in care. The staff vacancies need to be filled without delay to minimise the use of agency staff in the home and so provide consistency of care that people living there need. Staff must take appropriate action when taking water temperature tests rather than simply recording the values to ensure that people have safe and comfortable baths and showers. Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Fernlea DS0000001081.V343166.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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