Inspection on 10/04/07 for Fernlea Care Home

This inspection was carried out on 10th April 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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fernlea Care Home 22/04/08

Fernlea Care Home 10/10/06

Fernlea Care Home 09/01/06

Fernlea Care Home 12/07/05

Fernlea Care Home 21/02/05

Fernlea Care Home 28/06/04

Fernlea Care Home 13/01/04

Fernlea Care Home 10/02/03

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

CARE HOME ADULTS 18-65 Fernlea Care Home Sway Road Brockenhurst Hampshire SO42 7SG Lead Inspector Mrs Pat Hibberd Unannounced Inspection 10th April 2007 09:30 Fernlea Care Home DS0000037572.V333569.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 Fernlea Care Home DS0000037572.V333569.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. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernlea Care Home Address Sway Road Brockenhurst Hampshire SO42 7SG 01905 795088 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) fernlea@craegmoor.co.uk Craegmore.co.uk Park Care Homes (No 2) Ltd To be confirmed Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10) of places Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2006 Brief Description of the Service: Fernlea 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 property is a large detached house set in a large garden. It is located in the New Forest village of Brockenhurst, within walking distance of local amenities. Fernlea provides care for up to 10 residents with a learning disability and/or a mental disorder. All residents are accommodated in single bedrooms. The age range of the current service users (ten males) is 22-62 years. The current fees range from £659.24 to £1157.00 per week. The manager provided this information on the day of the site visit. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report included a site visit to the home on 10th April 2007 and information received by the commission since the last inspection in October 2006. During the site visit the inspector spoke with care staff on duty, the manager, and the area manager. Telephone calls were made to three relatives to gain an understanding of their views of the service provided at Fernlea. Discussions were held with six residents although, due to the communication needs of some residents accommodated staff support was provided to gain views of services provided in the Home. The interaction between other service users and staff were observed throughout the visit. A tour of the building was made and documents relating to the running of the home were inspected during the visit. Since the last inspection a new manager has been appointed. The term “resident” will be used throughout this report as requested by the Home as this is the preferred term of individuals accommodated. What the service does well: What has improved since the last inspection? Care plans seen for two residents demonstrated that they had been personalised to include the wishes of the resident. All care plans are now kept Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 6 under regular review to ensure the changing needs of the resident is being met. Risk assessments now provide information on how the risks could be minimised while still allowing the resident as much independence as possible. The Home has begun to introduce structured activities programmes for residents. Residents are now being offered a varied menu at lunch times and menus have been produced in a pictorial format. Records are now being kept of the one to one support received by residents as purchased by Adult services. Health appointments are no longer being cancelled due to staff shortages. Staff indicated that the new manager was providing consistent and supportive leadership with additional staff now employed on each shift enabling staff to feel they can provide the support needed to residents. Training records are now up to date enabling the inspector to confirm staff had received the training required to do their job. Fire records are now up to date. What they could do better: An up to date statement of purpose must be forward to the commission. Fire risk assessments must be undertaken of the specific needs of each resident in the event of a fire evacuation. All over the counter medication administered must be approved by the resident’s GP with written confirmation available for inspection. An occupational assessment must be undertaken for one resident with mobility needs. Two residents require a reassessment of their epilepsy needs by a health professional with a view to gaining an understanding of any adaptations required. The complaints procedure needs to be provided to residents in a format that is appropriate to their needs and understanding. All residents should be provided with a dining room chair, a shower curtain and flooring in the downstairs bathroom needs replacing and the hallway and stairs and landing need repainting. The patio to the rear of the Home needs a number of slabs re-laid as they are uneven and are a potential risk to residents and staff. A risk assessment needs to be undertaken of the patio area in the interim. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 7 Further risk assessments need to be undertaken of the steps from the kitchen doorway and hall doorway into the lounge area to ensure residents with mobility difficulties are not at risk from falling. External walls of the Home require painting and the windows replacing. 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 Care Home DS0000037572.V333569.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 Fernlea Care Home DS0000037572.V333569.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): Standard 2 were inspected on this occasion. Quality in this outcome area is good. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The file of one resident who had recently moved into the Home was inspected during the visit. A discussion was also held with the individual as to whether they had been involved in the pre assessment process. The file contained an assessment of their needs that was completed before they moved into the home. This assessment covers the individual needs of the resident, including communication, personal care and cultural needs. A copy of the residents’ care management assessment was also available. The resident said they had been fully involved in the pre assessment process, had visited the Home prior to moving in and considered the introduction to have “gone well”. The certificate of registration was displayed in the hall and reflected the residents accommodated. An up to date statement of purpose needs to be sent to the commission following the changes in manager and staffing in the Home. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 10 Fernlea Care Home DS0000037572.V333569.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): Standards 6,7 and 9 were inspected on this occasion. Quality in this outcome area is adequate. The home has care planning and risk assessment systems, which are regularly updated and generally reflect the support that service users need. Good support is provided to help residents make decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personal files of two residents were inspected during the visit and discussions held with the individuals and staff as to how there needs were being met. Both residents had a care plan that was developed from their initial needs assessment and was regularly reviewed, either monthly or when the needs of the resident had changed. Care plans contain details of how residents should be supported to make decisions. Staff support residents to make decisions about activities they take part in by using sign language, verbal communication and/or a set of objects of reference that has been developed for some residents. This support was Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 12 observed during the visit and was used in conjunction with Makaton sign language and provided in a sensitive and friendly manner. Risk assessments were in place for all residents whose files were inspected. These documents set out the assessed hazards to residents and action to minimise the risk of harm. The risk assessments had also been regularly reviewed, either every month or when the needs of the residents changed. Staff spoken with had a good understanding of the contents of the care plans and risk assessments. Please refer to the Personal and Healthcare Support section of this report for details of requirements made. Fernlea Care Home DS0000037572.V333569.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): Standards 12,13,15,16 and 17 were inspected on this occasion. Quality in this outcome area is adequate. Residents’ rights are respected and they are able to maintain contact with relatives and friends. Residents are benefiting from a more structured approach to providing suitable activities and are being offered a more varied choice of meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection visit residents were observed making decisions as to whether they wished to stay in their rooms or meet with others in the communal areas. Discussions held with two residents as to plans for the day indicated that staff were preparing to support them to pursue their chosen activity for the day. One resident attended a local college to obtain basic educational skills. Two other residents were involved in a garden project, which is supervised by the home’s activities worker and included residents doing gardening in the locality. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 14 The activities worker also supports residents to make items of woodwork in the workshop situated in the grounds of the home. One resident visits shops in the village as he wishes and records seen indicate that staff support other residents to access the community for shopping and visits to local pubs and cafes. Risk assessments are now in place for individuals accessing the community. One resident, supported by a staff member, attends services at a local church. Since the last visit to the Home structured activity programmes are now being introduced for residents. This was evident in files viewed and in discussion with residents and observation of staff support during the day. A staff member said that now there were more staff on duty they were able to provide one to one support for activities. Records seen indicated that service users were able to maintain contact with their relatives and friends. During the visits one resident was supported to understand when they were due to telephone their relative. One relative spoke to indicated that their relative was given opportunities to go out into the community but they hoped that with a new manager in post his options would increase as sometimes they felt residents did not get out and about enough. This had been discussed with the manager who indicated that all residents’ activity timetables were being reviewed. This will be followed up at the next inspection. Residents said that they enjoyed the food provided. Menus indicated that there is now a choice at lunchtime. Menus are now produced in a pictorial format ensuring they are accessible to all residents. However, it was evident that one resident continues to receive one of two main meals each day, fish fingers or sausages and chips. The manger explained that this was what the resident wanted. There were no records for other options offered to the resident and records seen did not indicate that advice had been sought to assist in developing a more nutritious diet although this had been discussed at the last inspection visit to the Home with the acting manager at the time. The new manager agreed to refer the resident to the local community health team for an assessment of their nutritional needs this will be followed up at the next visit. Fernlea Care Home DS0000037572.V333569.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): Standards 18,19 and 20 were inspected on this occasion. Quality in this outcome area is adequate. The home provides adequate support to meet the personal care and health needs of residents. The medication systems in the home generally protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records seen for two residents indicated that one to one time had been agreed with adult services for a varying amount of time per day/week. This is now being recorded and the one to one time is being received by residents. Staff spoken with said that this was due to the additional staff on duty. Visits by GPs and other health professionals including the district nurse and psychiatrist were documented in the residents care plans. The chiropodist also visited residents. At the last inspection visit it was evident that residents had missed appointments to health professionals due to staff shortages. Appointments were seen to now be taking place with one resident confirming that they had not missed any of their pre-planned visits to the GP or dentist. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 16 Individual medication records seen had been completed appropriately of medication prescribed by residents’ GP’s. However not all over the counter medication had been approved by the residents GP and a requirement was made the individuals GP to be consulted with documented evidence that this approval had been sought available for inspection. Staff administering medication had undertaken the appropriate training. A requirement was made for one individual to be referred to an occupational therapist for an assessment of their mobility needs as the accident book had a number of entries indicating that the resident had fallen. Although the Home are aware of the cause of the falls and the commission had been informed under regulation 37 the Home had not gained professional advice as to whether there was any environmental changes required to ensure the residents safety. It was further evident that for two resident’s who have a diagnosis of epilepsy hourly checks at night were being made by staff to ensure they had not had an epileptic fit. In discussion with the manager she indicated that she had identified an adaptation that would alert staff as to whether the resident had had a fit but did not have the funding to purchase the item. This adaptation had not however, been recommended or assessed as appropriate by a health professional and the manager agreed to refer the two residents for a reassessment of their epilepsy needs at night. Fernlea Care Home DS0000037572.V333569.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): Standards 22 and 23 were inspected on this occasion. Quality in this outcome area is good. Residents are confident their complaints will be taken seriously and acted upon although the complaints procedure is not accessible to all residents. The home has good adult protection systems, which help to keep residents safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond to a complaint. In discussion with one resident they were able to explain who they would talk to if they were unhappy with any aspects of service provision. The procedure is required, however, to be provided to residents in a format appropriate to their individual needs to aid understanding. One relative spoken with said they were more confident that following the appointment of the new manager any issues raised would be taken seriously. The relative was aware of the commissions website and how to contact the commission if they so wished to do so. Since the last inspection there have been no complaints received by the Home or commission. The home has an adult protection policy and a copy of the local authority adult protection procedures. Staff have received adult protection training and those spoken with demonstrated a good understanding of abuse and action to take if abuse was reported or suspected. There is currently one adult protection investigation underway which appears to have been dealt with appropriately by the Home. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 18 The money of one resident that was held by the home was inspected during the visit. The balance matched the records and receipts were available for purchases made on their behalf. Fernlea Care Home DS0000037572.V333569.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): Standards 24,28 and 30 were inspected on this occasion. Quality in this outcome area is poor. The home is not well maintained although, in general a safe and homely environment is provided for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fernlea is a detached house situated in a residential area of Brockenhurst, in the New Forest. Visitors to the home are admitted by a staff member and are asked to sign the visitor’s book. The visitor’s book contained times when visitors had signed on arrival at the home and when they had left the premises. Residents are accommodated in single rooms. All the rooms have a toilet and washbasin and two also have a bath and another a shower. There are also two separate bathrooms and a shower room. A shower curtain and the flooring in the downstairs bathroom were required to be replaced as they were stained. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 20 The inspector viewed a number of residents’ bedrooms. The rooms had all been personalised by the residents and contained many items such as televisions, DVD players, posters and pictures. All residents spoken to said that they liked their rooms. The home has a lounge with dining area, a dining room that is not often used by residents, but is used by staff for handover meetings and is where the medicines are stored. It was noted however, that there were insufficient chairs for the number of residents accommodated. The manager explained that this was due to a number being broken by residents. A requirement was made for all residents to have a dining room chair to sit on. The kitchen is domestic in type and there is a laundry room. Hazardous substances such as cleaning fluids were locked in a cupboard. Rooms seen looked clean and homely. However, many of the communal areas required painting and a requirement was made to this effect. The exterior of the building remains in need of attention with some windowsills in a poor state of repair and the walls needing a coat of paint. This has been an outstanding requirement from two inspections undertaken of the Home although, had not been brought forward as a requirement at the last inspection in October 2006 as the work agreed to be undertaken by the Provider be the end of December 2006 had not been reached. Despite the commission receiving written notification on 19.01.2007 that all windows and doors are in the process of being replaced and a redecoration plan is being implemented this work has not commenced and no date could be confirmed during this inspection. A discussion was held with the area manager who confirmed that due to the costing involved the request for funding had to be made to the Board that had resulted in a delay. A new timescale was made for all works to be completed by June 2007. The area manager agreed to write to the commission confirming this would be completed. There is a large garden to the rear of the property with parking space and there is also a small parking area at the front of the home. A resident said that he had enjoyed sitting in the garden and looked forward to having a barbeque in the summer. However, the patio to the rear of the Home needed a number of slabs re-laid, as they are uneven and are a potential risk to residents and staff with the accident book having an entry of a staff member tripping on an uneven paving slab. A risk assessment was required to be undertaken of the patio area on the day of the inspection visit. Further risk assessments need to be undertaken of the steps from the kitchen doorway and hall doorway into the lounge area to ensure residents with mobility difficulties are not at risk from falling. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 21 Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 22 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): Standards 32,34 and 35 were inspected on this occasion. Quality in this outcome area is good. The home has good systems to protect residents and meets their needs through the staff training programme and recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three of the ten staff employed have achieved the National Vocational Qualification (NVQ) at level two or above with a number of others undertaking the qualification. The manager reported that staff would be supported to complete the work required of which staff confirmed they were receiving. During the visit, staff were observed interacting with service users in a friendly and respectful manner. The records of two staff were inspected including one staff member who has been employed since the last inspection in October 2006. These records contained two written references and a Criminal Records Bureau (CRB) disclosure. The manager reported that CRB disclosures had been obtained for all staff working in the home. Staff spoken with said that they received very good training, which helped them to meet the needs of residents. A record is kept of all training that staff have undertaken and staff appraisals include a training needs assessment. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 23 One staff member recently appointed said that they had undertaken a thorough induction including shadowing a senior member of staff prior to lone working with residents. Further comments received from staff included how the manager had acknowledged and met their cultural needs of which they indicated had made them feel very supported. Courses staff have completed include first aid, medication administration, food hygiene, fire safety, health and safety, infection control, adult protection, moving and handling, epilepsy, Makaton sign language and autism. All staff spoken with confirmed they are receiving supervision and that the new manager is being extremely supportive. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 24 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): Standards 37,39 and 42 were inspected on this occasion. Quality in this outcome area is adequate. The home is run by a manager who is taking action to promote the health, safety and welfare of residents and staff and uses feedback from residents and their relatives to plan improvements to the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new manager has been appointed since the last inspection and indicated that she will be applying for registration with the commission shortly. Staff spoken with commented on how supportive the manager was and how the service and systems had improved since her appointment. The manager was seen to interact positively with both residents and staff throughout the inspection. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 25 A staff member said that residents were encouraged to give their opinions about life at the home as they wished and were supported to participate in decision making during residents’ meetings that now take place monthly. Residents spoken with said they were happy with life in the Home and could talk to staff and the manager. The organisation conducts a survey to obtain the views of residents and their relatives on the quality of care provided in their homes annually this is an initiative introduced called “Your Voice” which ensures residents are listened to and that their views are valued. Training records were up to date indicating that all staff had received training in mandatory sessions such as moving and handling and food hygiene. Fire records seen were up to date and all staff spoken to confirmed that they had attended fire drills. Maintenance records seen were also up to date. Whilst the Home has a general evacuation plan in the event of a fire the manager was required to ensure all residents have an individual risk assessment of their needs in the event of a fire evacuation. Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 26 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 1 25 X 26 X 27 X 28 2 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 3 X X 2 X Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 27 Yes 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. 2. Standard YA1 YA8 Regulation 4 Requirement Timescale for action 17/04/07 10/04/07 An up to date statement of purpose must be forward to the commission. 13(4) ( c ) Fire risk assessments must be undertaken of the specific needs of each resident in the event of a fire evacuation. 13(2) All over the counter medication administered must be approved by the resident’s GP with written confirmation available for inspection. An occupational therapy assessment must be undertaken for one resident with mobility needs. Two residents require a reassessment of their epilepsy needs by a health professional with a view to gaining an understanding of any adaptations required. The complaints procedure needs to be provided to residents in a format that is appropriate to their needs and understanding. DS0000037572.V333569.R01.S.doc 3. YA20 13/04/07 4. YA19 13(1) (b) 10/05/07 5. YA19 13(1) (b) 24/04/07 6. YA22 22(2) 24/04/07 Fernlea Care Home Version 5.2 Page 28 7. 8. 9. YA28 YA24 YA24 23(2) (g) 23(2) (b) 23(2) (0) 10. YA24 13(4) (a) All residents should be provided with a dining room chair. Flooring in the downstairs bathroom needs replacing. The patio to the rear of the Home needs a number of slabs re-laid as they are uneven and are a potential risk to residents and staff. A risk assessment needs to be undertaken of the patio area to the rear of the Home. Risk assessments need to be undertaken of the steps from the kitchen doorway and hall doorway into the lounge area to ensure residents with mobility difficulties are not at risk from falling. External windows require replacing. This requirement is outstanding from two previous inspections with a timescale for completion of 31/12/2006. External walls of the Home require painting. This requirement is outstanding from two previous inspections with a timescale for completion of 31/12/2006 The hallway, stairs and landing need repainting. 13/04/07 10/06/07 10/05/07 10/04/07 11. YA24 13(4) (a) 10/04/07 12. YA24 23(2) (b) 10/07/07 13. YA24 23(2) (b) 10/06/07 14. YA24 23(2) (d) 10/07/07 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 Good Practice Recommendations DS0000037572.V333569.R01.S.doc Version 5.2 Page 29 Fernlea Care Home Standard Fernlea Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Care Home DS0000037572.V333569.R01.S.doc Version 5.2 Page 31 - 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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