Inspection on 24/03/06 for Fernlea Residential Home

This inspection was carried out on 24th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fernlea Residential Home 19/12/08

Fernlea Residential Home 04/01/07

Fernlea Residential Home 25/09/05

Fernlea Residential Home 03/02/05

Fernlea Residential Home 30/09/04

Fernlea Residential Home 12/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Fernlea Residential Home 114 Sandon Road Meir Stoke-on-trent Staffordshire ST3 7DF Lead Inspector Rachel Davis Unannounced Inspection 24th March 2006 11:30 Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fernlea Residential Home Address 114 Sandon Road Meir Stoke-on-trent Staffordshire ST3 7DF 01782 342822 01782 342822 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) Priorcare Homes Limited Mrs Rachael Foden Care Home 13 Category(ies) of Learning disability (3), Physical disability (13), registration, with number Physical disability over 65 years of age (8) of places Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2005 Brief Description of the Service: Fernlea is located on the outskirts of Meir, Stoke-on-Trent and is within walking distance of a post office, a small supermarket, a fish and chip shop, a newsagent’s and a post office. The property is set back from the main road, adequate parking is available. Fernlea provides care and accommodation for up to thirteen service users with a physical disability, eight of who may be over 65. Fernlea also has the facility to care for three adults with a learning disability. All accommodation is single storey, all the bedrooms are singles but none have an en-suite facility, not all of the bedrooms meet the minimum twelve sq metres standard size. A spacious lounge dining room and a large recreation room provide adequate communal space for the currently fully occupied home. Access to kitchen is limited due to the domestic style and size; however, a kitchenette area has been created in the recreation room to enable service users to remain as independent as practicable. Bathing facilities are provided in a spacious assisted bathroom and a separate walk-in shower room. Two additional assisted toilet facilities are also provided. The home has a good sized patio and rear garden which is well used during the warmer months. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on 24th March 2006. The inspector used the National Minimum Standards for Younger Adults and Older People as the basis for the inspection. This visit only covered a small number of the national minimum standards, to ascertain a full picture this report should be read alongside the unannounced inspection held in September 2005. All 13 service users were at Fernlea on arrival, two staff were on duty on each shift, the manger was not included in these numbers. The inspector spoke with all of the service users to varying degrees, two staff and the manager Rachael Foden. What the service does well: Generally people are happy living at Fernlea. “I do things in my own time ” “ I like the smallness of the home and I like the people.” “My life here is flexible ” “The food is excellent.” “ The staff are brilliant ” were some of the comments made. Service users spoken to felt that the staff listen to them and said that they would sit with them on their own to talk about any issues. Minor grumbles are dealt with so that these don’t grow into bigger problems. The recording of such would prove invaluable as evidence for future inspections. The home has a committed staff team and it was clear that staff and service users got on well together. The staff were well supervised and felt supported by their manager. Staff revealed that “ Rachael is approachable” and that “we communicate well as a team.” Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 6 The homes documentation on care delivery was positive and meaningful. The general consensus was that meals provided at Fernlea were of good quality. The requirements made at the last inspection have been met. What has improved since the last inspection? What they could do better: The staff still require mandatory training in some areas. A number of risk assessments still require implementation; for example: hoists, window openings and glazing, contractors, cross infection, wheelchairs, Legionella, this list is not exhaustive. Provision of such will help to ensure the safety of all those working and living at Fernlea. It would be better if more information were available to confirm what service users had to pay for over and above the fee level. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 7 The home must ensure that food stuffs in the fridge and freezers are dated and identified to minimise and risk of any infection. Recruitment procedures need to be more robust Protection of Vulnerable Adult (POVA) checks on two staff could not be found, recruiting staff before all the necessary checks have been undertaken potentially leaves vulnerable people at real risk. The complaints procedure requires some amendments to confirm that an individual can complain to the Commission for Social Care Inspection at any time, not just following the homes own investigation. Control Of Substances Hazardous to Health (COSHH) products must be stored in a locked area. Ten requirements and five recommendations were made as a result of this unannounced inspection. 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. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 The Statement of Purpose and Service User Guide were comprehensive and informative documents offering service users, prospective service users and their families adequate information. EVIDENCE: The establishments Statement of Purpose and Service User Guide are sited by the visitors book and offers current and prospective service users and significant others the opportunity to make an informed choice about the services provided and whether the home can meet their needs. The complaints procedure will need to be altered within these documents to meet the requirements. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 10 It is advised that the management team streamline some of their information to ensure that it is absolutely clear about what the home does and does not provide and what the service users may be expected to finance themselves. The manager confirmed that there had not been any new admissions to the home since 2004. There was evidence to confirm that information relating to the admission process was in need of slight amendments, the home must ensure pre assessments competed by the home are robust, no service user should move into the home without having the assurance that his or her assessed needs would be met. A contract was not available on the day of the inspection; the Commission has asked the home to forward blank contract documentation to the inspector at their earliest convenience to ensure that it meets requirements. Responses from the service users confirmed that staff responded flexibly to their day-to-day needs. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected and were covered on the inspection held in September 2005. EVIDENCE: Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15 Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 13 The lifestyle for the service users varies according to their wishes and capabilities, with greater support offered from staff where needed. Visitors are made welcome and various avenues for encouraging service user choice are in place both within the home and the local community. More emphasis needs to be placed on the recording of activity planning. EVIDENCE: Service users were spoken with and it was clear that they were involved with the local community and maintained a neighbourly relationship. Care plans revealed that service users who so chose went to the theatre, the cinema, college, the local pub and visited their families and friends. One visitor was seen supporting a service user with his college work and another service user confirmed that his family and friends visited often and were always made welcome. There was reliable evidence of regular minuted service users meetings taking place, but it was difficult to ascertain if requests and/or concerns voiced were followed through. A couple of service users revealed that they did on occasion feel bored, without robust recording it is difficult to evidence the choices offered by the home, whether an individual chose not to participate with the activity, or the time spent with them. Discussions with the manager revealed that the home felt they were proactive in this field and gave good examples of stimulating and worthwhile activities. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected and were covered on the inspection held in September 2005. EVIDENCE: Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Further information is required to enable service users and their representatives an understanding of the options available to them relating to lodging a concern or making a complaint. EVIDENCE: The complaints procedure is available within the Service User Guide but it does not fully meet the legislative requirements. The complaints procedure was also sited within the home near to the front door. The procedure needs to confirm that service users may speak with the Commission for Social Care Inspection and make a complaint (if they so wish) at any time, at present it suggests that the Commission would only be notified if the complainant was not satisfied with the outcome. A complaints log was not in place, this is strongly recommended; such information provides evidence to show that service users are comfortable and feel able to raise their concern or point of view. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 16 The home had a suitable policy and procedure document in place for responding to suspicion or evidence of abuse or neglect, including a Whistleblowing Policy. A copy of the local multi-disciplinary procedure to be followed (both Staffordshire and Stoke on Trent), and a copy of the Department of Health document entitled ‘No Secrets’ were available. The staff individual files and over-arching training file provided evidenced that staff have attended a course on the Protection of Vulnerable Adults. The content of this course was discussed with the manager, whilst it was considered to be generally suitable, the home is recommended to consider providing further training to enhance staff knowledge about local procedures to follow and good practice issues relating to the ‘No Secrets’ document. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The home is at an acceptable standard environmentally; service users movements are hindered by the narrowness of the corridors and hallways. EVIDENCE: Fernlea has been open for approximately 20 years due to it being a long established home it does not fully meet with the national minimum standards. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 18 The home is in keeping with the local area and is fairly indistinguishable as a care home. There is good access to local amenities and public transport. The furniture and fittings are comfortable and are domestic in character. The communal areas of the home are nicely decorated and the overall impression is of a pleasant home, although some areas would benefit from ‘finishing touches’ to give a more homely feel. The carpet outside room 5 is in need of repair and COSHH products must be locked away, it was considered appropriate to lock these products in laundry area and have a risk assessment in place for busy periods in the day when the laundry may remain unlocked. Service users rooms were individualised and everyone seemed happy with their personal space. The last inspection recommended that the bathrooms and toilets should be upgraded. The proprietor has taken these comments on board and revamped these areas. The home uses liquid soap and paper towels for hand washing to help prevent cross infection in all the bathrooms and toilets, infection control training has also been provided to all the staff. Personal protective equipment was available and sited appropriately and the clinical waste was collected on a weekly basis. The home was clean and standards of hygiene were satisfactory; no requirements in this discipline were made on this visit Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 The home has a fairly consistent and stable staff team, however, the recruitment procedures and training are not as robust as they should be and therefore do not fully provide all the safeguards for those people receiving the service. EVIDENCE: In addition to the manager there is a small stable staff team of 12, six senior care and six care staff. All senior care staff are qualified to NVQ 2 or above, and the care staff have recently enrolled on the same course. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 20 Two files pertaining to members of staff working in the home was randomly selected for examination, medical declarations to confirm that the staff were both physically and mentally fit for purpose and a photograph were not in place as required. One file confirmed that a Criminal Record Bureau disclosure or the necessary Protection of Vulnerable Adult (POVA First) could not be found. The absence of such vital information could potentially put vulnerable people at real risk, the manager was asked to deal with this as a priority. The manager has just started to complete a training matrix; this will cover mandatory training such as training in food hygiene, health and safety, moving and handling, medication training, fire safety and infection control. Dates when training took place were being added and the manager should also consider adding when the refresher training is due. The responsible individual must ensure that all mandatory training is provided to all staff. On this visit it was identified that the member of staff cooking lunch did not have a basic food hygiene certificate and had not received the training, a staff file also revealed that moving and handling training had not been provided to a new member of staff. It was also identified that the underarm lift was used on occasion; this practice is not suitable for the service user or the staff and must cease. It was also recommended that staff should be offered training in specialist areas pertinent to those living at Fernlea. A suitable and adequate induction is offered by the home. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,42 The views of the service users are sought and the quality of care is monitored and addressed accordingly. The monitoring of health and safety practices needs to be strengthened to ensure that the service users and staff are as safe as reasonably practicable. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 22 EVIDENCE: Service users were generally very satisfied with the home comments made included: “ I feel safe” “ It’s a good team” “Rachael and the staff understand my needs” Due to the fact this home is dual registered, the manager should obtain a copy of the Care Homes for Older People National Minimum Standards as well as the Younger Adults Standards, which were available. Service users confirmed that they were actively involved in the home and felt well informed. A number of requirements were made regarding the recording of information, The responsible individual must ensure that products stored in the fridge and freezer are labelled and dated to minimize the chance of food poisoning or the use of out of date stock, there were various instances where this was not occurring. Daily temperatures of the appliances were being completed as necessary, the manager must monitor the fridge and possibly implement a risk assessment as temperatures should not go over 5 degrees, records confirmed this was happening on a number of occasions. The manager needs to implement and record a number of risk assessments, it was clear that the risk assessments in place were apt and also reviewed or revisited as and when required. However a number of assessments were missing, examples of these include: The use of hoists, window openings and glazing, contractors, cross infection, wheelchairs, Legionella, unlocked laundry, this list is not exhaustive. Fire risk assessments were completed and reviewed as required, however, the responsible individual must complete a written contingency plan in the event of a fire or bomb threat regarding safe placement of service users. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 2 43 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fernlea Residential Home Score X X X X DS0000008228.V288738.R01.S.doc Version 5.1 Page 24 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 YA2 Regulation 14 (1) Requirement The responsible individual must ensure that future needs assessments undertaken contain all of the information recorded under NMS2.3. The responsible individual must ensure that the complaints procedure is clear in the fact that service users or their significant other may make a complaint to the Commission at any stage and independently from the home. The responsible individual must ensure that COSHH products are locked away. The responsible individual must ensure that the carpet outside room 5 is secured The responsible individual must ensure that all information referred to in Schedule 2 is acquired. The responsible individual must ensure that all mandatory DS0000008228.V288738.R01.S.doc Timescale for action 01/05/06 2 YA22 22 (2) (6) (b) 01/04/06 3 4 5 YA24 YA24 YA34 13 (4) 13 (4) 19 (1) (b) (i) 18 (1) © Ii) 01/04/06 24/04/06 01/04/06 6 YA35 01/05/06 Fernlea Residential Home Version 5.1 Page 25 7 YA42 13 (4) © 8 YA42 13 (4) © 9 10 YA42 YA42 13 (4) (a) 24 (4) © (iii) training is provided to all staff. The responsible individual must ensure that ensure fridge temperatures are maintained at safe levels The responsible individual must ensure that products stored in the fridge and freezer are labelled and dated. The responsible individual must ensure that risk assessments are completed in all instances. The responsible individual must complete a written contingency plan in the event of a fire or bomb threat regarding safe placement of service users. 01/04/06 01/04/06 24/04/06 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations It is advised that the management team streamline some of their information to ensure that it is absolutely clear about what the home does and does not provide and what the service users may be expected to finance themselves. The home should consider holding a complaints and comments log. The home should facilitate training and or information relating to the local procedures to follow following a vulnerable adult allegation. The home should consider specialist training specific to individual service users needs The manager should obtain a copy of the Care Homes for Older People National Minimum Standards. 2 3 4 5 YA22 YA23 YA35 YA37 Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Fernlea Residential Home DS0000008228.V288738.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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