Inspection on 30/05/07 for Fernleaf Care Home

This inspection was carried out on 30th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fernleaf Care Home 14/06/06

Fernleaf Care Home 06/02/06

Fernleaf Care Home 13/07/05

Fernleaf Care Home 07/03/05

Fernleaf Care Home 09/12/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Fernleaf Care Home 26 Chesterfield Road South Mansfield Nottingham NG19 7AD Lead Inspector Stephen Benson Key Unannounced Inspection 09:30 30th May 2007 X10015.doc Version 1.40 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 Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernleaf Care Home Address 26 Chesterfield Road South Mansfield Nottingham NG19 7AD 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) 01623 655455 01623 406370 info@bhcarehomes.co.uk WWW.bhcarehomes.com Bank House Care Homes Ltd Mrs Jeanette Sheppard Care Home 21 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (21) of places Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Fernleaf Care Home is registered to provide personal care to service users of both sexes whose primary needs fall within the following categories:Old age not falling into any other category (OP) 21 2. Dementia - up to 60 years of age (DE) 4 The maximum number of persons to be accommodated at Fernleaf Care Home is 21 14th June 2006 Date of last inspection Brief Description of the Service: Fernleaf is a care home providing personal care and accommodation for up to 21 older people and has four beds allocated to care for people with dementia. The home provides short term, long term or respite care and accepts emergency admissions subject to bed availability. The home is owned by Mr. and Mrs. Sooriah, trading as Bank House Care Homes Limited, and is a run as a family business. The home is located in Mansfield town centre and is close to shops, pubs, the post office and other amenities. The home was opened in January 1985 and consists of a former hotel building with extensions added. 19 of the homes bedrooms are single, and 9 of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger lift. There are 3 bedrooms on the first floor that are accessed by 3 steps, which have a stair lift fitted. The home has an enclosed garden to the rear, which is easily accessible. There is car parking available for up to 8 cars to the front of the home in a small car park. The manager said on 30/05/06 that the fees for the service range from £290 £344 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available in the brochure and service user guide or from the website: WWW.bhcarehomes.com The manager or provider welcome any telephone enquiries and a copy of the latest inspection report is available in the office. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The site visit lasted for 5 ½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the providers, the manager, staff on duty and care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. Survey forms sent to the home by The Commission for Social Care Inspection had been completed by the majority of residents. The registration certificate was checked and found to be incorrect and a new one has been requested. What the service does well: Care plans clearly describe how resident needs are to be met and a care plan is written where a need is identified. This ensures that staff know how to meet residents’ needs. The home contacts healthcare professionals to see to the healthcare needs of residents. This ensures that the healthcare needs of residents are met. Staff are trained to respect the privacy and dignity of residents and know good practices for doing this. This ensures that residents’ privacy and dignity are promoted. Residents are able to take part in a wide range of activities as part of a group and individually. This ensures that residents have opportunities to do things they find meaningful and enjoyable. Visitors to the home are welcome and can take residents out. Residents have opportunities to go on trips out of the home. This ensures that residents are able to maintain relationships with families and friends. Residents are able to choose how they spend their time and are supported by staff to make choices where they are able. This ensures that residents remain in control of their lives. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 6 There is a varied menu providing a choice at each meal and further alternatives are available. The dining room is well presented. This ensures that residents have a nutritious and balanced diet in pleasant surroundings. The home has a complaints procedure, which is easy for residents to use and has been used to sort out small issues that arise in communal living. This ensures that residents can raise anything they are not happy about which is then resolved. The home has policies and procedures for staff to follow if they suspect anyone is not being properly treated. This ensures that residents are protected from any form of abuse. The home is suitably decorated and furnished and kept in a good state of repair. This ensures that residents live in a safe and well maintained environment. The home is kept clean and tidy and there are measures in place to prevent the spread of infection. This ensures that residents are not at risk of becoming infected. The home provides three staff on duty during the morning and two staff in the afternoon and at night. There are staff who work in the kitchen and keep the home clean. This ensures that staff are available to see to residents needs. All staff have either completed or are working towards National Vocational Qualifications relevant to their role in the home and regular training is provided. This ensures that residents are cared for by people trained to meet their needs. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check and obtaining satisfactory references. This ensures that residents are cared for by people who are suitable to look after them. There is a suitably experienced manager in post who is working towards a recognised qualification. The providers are actively involved in much of the day to day running of the home. This ensures that the home is properly run in the best interest of residents. Residents are able to express their views on how the home is run through meetings and completing questionnaires. This ensures that residents can have a say in how the home is run. Regular checks and tests are carried out on the building and equipment. This ensures that the health and safety of residents is protected. What has improved since the last inspection? Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 7 There have been improvements made in many areas of the home as part of the development of the home’s services, including the décor, mealtimes, care planning, opportunities for leisure activities and staff training. This ensures that residents live in a home where standards are continually being improved. The home will hold money for residents so they can make any purchases they want to. All transactions are signed for by 2 people. This ensures that residents’ financial interests are safeguarded. 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. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service EVIDENCE: The manager said that either she or the provider go to assess any prospective new resident. The home has their own assessment form to complete to help assess their needs. There were copies of assessments completed by Social Services seen on residents’ files and these had arrived before the resident moved into the home. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 10 Assessments included details of any specialist assistance a resident requires. Some of the detail was on the brief side and these would be improved with greater detail. Staff said that they read the assessments and care file before a resident moves in and that information is always available before someone comes in. The provider said that anyone is welcome to apply for a place providing they fall within the registration category for the home. A new brochure and service user guide have been prepared. The manager said that there are male and female residents who are of white British or Polish origin. No recently admitted residents were available to discuss the admission process with. There is no arrangement made for the home to provide an intermediate care service. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social needs are set out in an individual plan of care and these are met by care practices in the home. EVIDENCE: The manager said that a lot of work has gone into improving care plans in the home and that this is continuing. A sample of five care plans were seen and these were all well ordered. They were broken down into twelve areas of care including health care, mobility and social needs. Care plans contained clear instructions on the assistance a resident requires including the number of staff needed and any equipment necessary There was a form signed by residents or their relatives to say they had discussed the care plan and showed they had been made aware when it had been updated. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 12 The manager said she has recently introduced a key worker system and one of the responsibilities was to keep the care plan up to date. The manager said that this was working well and that she was working on making greater use of risk assessments. One of the providers said that she carries out spot checks on care plans and a list of things needed to bring one plan up to standard was seen. The provider said that the next development for care plans is to prepare a social history for each resident. Staff said they use care plans everyday to record information in and to look up details. The way staff spoke about care plans showed that they understood them and use them regularly. A resident said, “I am happy with the care I get, I can say how I want it”. In survey forms completed by residents, 12 residents said that they always receive the care and support they need and 2 said they usually do and 1 said they sometimes do. A record is made of all healthcare appointments and these showed that healthcare needs are being met. Records showed that one resident had some new dentures and was taken back to the dentist, as they were not fitting properly. There was a record of a dietician being consulted and the advice given was included in the care plan. Records also showed that district nurses and doctors regularly visit the home and community psychiatric nurses and the psychogeriatrician are involved with some residents. Staff were aware of the need to monitor the health of residents without speech and said they can tell if a resident is not feeling well through such things as the way they move, change in appetite or their body language. Staff said they will discuss any concerns with other staff and call a doctor if needed. A resident said, “I am asked how I am feeling”. One resident said he had mislaid his glasses and a member of staff went and found them. In survey forms completed by residents, 12 residents said that they always receive the medical support they need 2 said they usually do and 1 said they sometimes do. Only staff who have been trained on the safe handling and administration of medicines give out medication. The manager said that medication reviews are carried out and there has not been a drug error made. One resident self medicates all their medication and another some of it. There was an agreement form for this signed in the care plan and the manager Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 13 described having assessed this as safe to happen, but there was not a written assessment for this. The manager has carried out an internal audit of the home, which included the home’s medication procedures. This found everything to be correct. Staff described the correct procedures to follow when administering medication and were seen following these when administering medication at lunchtime. Medicine Administration Records were fully completed. A resident said, “Staff give out the medicine, they don’t forget it and never run out of it”. The manager said that respecting residents’ privacy and dignity is included in the induction of new staff and the home has a policy for this. The manager said that she observes practices to make sure that staff are promoting residents’ privacy and dignity. The provider said he is introducing a system of a member of staff being a privacy and dignity ‘champion’ in the home to promote good practices. Staff were aware of good practices in promoting residents’ privacy and dignity, including maintaining confidentiality, encouraging residents to do as much for themselves as possible and when assisting with personal care to prevent embarrassment. A resident said, “I think they respect my privacy pretty well, but I’m not bothered about that at my age!” Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to satisfy their social, cultural, religious and recreational interests and needs through opportunities provided within the home, the local community and being able to maintain relationships. Residents are helped to exercise choice and control over their lives and receive a wholesome and balanced diet. EVIDENCE: The home now has an activities coordinator who is responsible for arranging activities five days a week. A record is made of activities provided and these showed that skittles, bingo, dominoes and pottery have all been provided. Residents were seen playing bingo, colouring, reading, watching television and listening to music. The provider took a turn at calling out the numbers in the bingo. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 15 The provider said he has arranged for broadband to be connected to the home and residents will be able to access the Internet. The provider said he will be arranging some tuition to help residents do this. The manager said that one resident of Polish origin enjoys spending time with a Polish member of staff and speaking their language. One resident spoke about feeding the birds and the staff said that residents have been planting seeds in the garden. Staff said that some residents don’t want to join in any organised activity, but they are always offered the opportunity. A resident said, “There are things organised for us to do”. In survey forms completed by residents, 12 residents said that activities are arranged by the home they can take part in, 1 said they usually are and 1 said they sometimes are. One resident wrote there is a lack of post and banking facilities. The provider said he would arrange for a post box to be in the hall for residents to post any letters in and the manager said she would discuss with the resident about banking facilities. Visitors are welcome to the home at any time and able to take resident out. The manager said that some residents attend a local church. Staff said that trips out are organised and six residents recently went to see Kiss Me Kate at the local theatre. Staff and residents were heard discussing the opening of a new supermarket opposite the home and were making plans to go shopping and have a drink there when it opened. The manager said that residents are asked what they want to do and that they can choose their own routines. One resident likes to stay in bed until late morning and then have breakfast. Staff said that residents tell them what they want to do and they try their best to accommodate requests, for example walking around the garden. Staff described appropriate ways of offering choices to residents with dementia. A new four week menu has recently been introduced and daily menus have been laminated and are going to be put on each table. The main meal is at lunchtime and this is a three-course meal with a soup starter. There is a different type of fish on Fridays and a roast dinner on Sundays. There is a choice at each meal and more modern dishes are included, such as chicken in white wine, pizza and lasagne as an alternative to Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 16 more traditional dishes such as toad in the hole, hot pot, roast chicken and grilled steak. A lighter meal is had at tea time, again with a choice of dish with such things as sweet and sour pork, ploughman’s lunch and sardines on toast. A pudding is provided at lunch and teatime. The provider said that the menu had been designed around the needs of the residents and this would be changed as and when this was needed to meet residents’ needs and preferences. The cook is in the process of carrying out a nutritional assessment for each resident, which includes any special diets, likes and dislikes. Some also stated dishes residents would like to try. Cold drinks were available for residents to help themselves and hot drinks, fruit and biscuits were provided mid morning. Dining tables were well laid with flowers and linen serviettes on. Lunch was minestrone soup, a choice of gammon with pineapple or corned beef hash. There was a choice of vegetables and potatoes or chips followed by pineapple sponge, fruit salad or ice cream. One resident had a vegetarian meal. Staff were seen asking residents to choose what they wanted. The meal was well presented and good sized portions were served. Residents said they enjoyed the meal. In survey forms completed by residents, 10 residents said that they always like the meals in the home and 5 said they usually do. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel able to complain if something is not to their liking. EVIDENCE: The home has a complaints procedure and a book to record any complaints in. There were 5 complaints recorded in the last 12 months. Records of complaints made included details of the investigation and outcome, although these did lack details. Completed forms are put on residents’ files, however this makes it more difficult for the manager to monitor, who said she would start using a central record as well. Complaints made were about a creased tablecloth, laundry problems and a bed not being made. All complaints were made by residents and recorded by different staff. Records indicated that residents were satisfied with the outcome of their complaint. In survey forms completed by residents, all the residents said that they knew how to make a complaint. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 18 The manager said that whichever member of staff hears a complaint should fill in the complaints form. Staff were aware of the procedure. A resident said, “I could complain if I wanted to, but I don’t need to”. There was a copy of the Adult Protection Procedures, which were up to date. The home has a whistleblowing policy. Staff have received training on safeguarding adults. Staff said that fire doors are alarmed so they know if a resident is trying to leave the building and the front door has a keypad on. The manager said there have not been any reported incidents of abuse and that any form of abuse or discrimination would not be accepted and would be dealt with by following the Adult Protection Procedures. A resident said, “I feel perfectly safe here, no worries at all” Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The providers have continued with a programme of improvements to the decor of the home and said that the upstairs landing is to be decorated and the dining room modernised and decorated. A resident was seen getting around in the home using an electric wheelchair. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 20 The manager said that all repairs are recorded in a maintenance book and seen to promptly. They most recent fault recorded in the book to a toilet was fixed the following day. Staff said that any repairs are attended to promptly and they can call the handyman if anything is urgent. A resident said, “I can get around everywhere using my frame”. The manager said that there are two cleaners on every day. Staff said that the home is kept clean and there is protective clothing readily available. Staff said they have had infection control training and that they were doing a further more in depth course. Residents said they thought the home was kept to a high standard of cleanliness. In survey forms completed by residents 14 residents said that the home is always fresh and clean and 1 said it usually is. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient and suitably trained staff employed at the home, ensuring that residents needs can be met. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The home has assessed their minimum staffing levels to be 3 care staff in the morning and 2 staff in the afternoon and at night. In addition the home employs a cook, kitchen assistant, handyman and cleaners. At present all care staff are female, although male carers have been employed in the past. Staff are of varying ages and from a white British and Polish background. Staff said they felt there are enough staff on duty for them to be able to carry out their duties. A resident said, “There seem to be enough staff, they come pretty quickly when I use the call bell”. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 22 In survey forms completed by residents, 6 residents said that staff are available when you need them and 9 said they usually are. All care staff have completed National Vocational Qualification level 2 with the exception of one person who has only recently started at the home, and she is planned to enrol shortly. Two care staff have completed National Vocational Qualification level 3 and two more are currently working towards this. The cook and domestic staff are also doing National Vocational Qualification level 2 in their service areas. One of the providers is a National Vocational Qualification assessor and was at the home working with staff on their portfolios. Staff files seen showed that the correct recruitment practices are followed, including obtaining references and Criminal Records Bureau checks, although one reference seen was not from an appropriate person as they were a personal friend. The home follows their equal opportunities policy in the recruitment of new staff. The provider said that all training is up to date and there was a rolling programme to provide all mandatory training. In addition other training is organised for example a local doctor is providing training on head injuries and diabetes awareness. A copy of all staff certificates are kept in the training file. The manager has been on an equity and diversity course and this course is to be provided to staff. There is training planned on moving and handling and health and safety over the next month. Staff said that there are regular training opportunities available and they can suggest any training the think will be of benefit. Staff said the course they did on dementia last year had been very good. A resident said, “Staff seemed to be properly trained”. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable management systems in place for the smooth running of the home and to protect residents. Residents express their views on how the home is run. EVIDENCE: The manager has worked at the home for 5 years and has been the registered manager since August 2006. The manager is working towards National Vocational Qualification level 4 and expects to complete this by September 2007. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 24 Staff said that the manager is approachable as are the providers who attend the home regularly. A resident said, “The home seems well run to me”. The home achieved Investors in People status on 15th May 2007. The manager showed survey forms completed by residents in January 2007. There are residents meetings held, the last one was in March 2007 when residents suggested inviting the mayor of Mansfield to attend to Easter bonnet parade, which he did. The provider has prepared an annual audit, which the manager is completing. Staff said that they have asked residents to fill in survey forms and a resident said, “I filled in a questionnaire”. The home will hold money for residents to pay for hairdressing, chiropody and other incidentals. A record is made of each transaction and signed and witnessed. Receipts are kept when available. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. Dates of tests were recorded in the pre inspection questionnaire showing they are regularly carried out. Staff said they have recently held an evacuation of the home as part of their fire training. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 12(2) Requirement A written assessment must be carried out on any resident who self medicates. This will ensure that it is safe for them to manage their own medication. Timescale for action 11/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP16 OP29 Good Practice Recommendations Include more details of resident needs and wishes when assessing prospective new residents. This will ensure that all residents needs can be planned for and met. Include more details of any complaint investigation. This will ensure that any complaint made if fully investigated. Any references obtained for new staff must be from an appropriate person. This will ensure suitable people are employed to care for residents. Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Fernleaf Care Home DS0000052265.V340684.R01.S.doc Version 5.2 Page 28 - 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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