Inspection on 29/05/08 for Fernleigh Care Home

This inspection was carried out on 29th May 2008.

CSCI found this care home to be providing an Good service.

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

Fernleigh Care Home 08/05/09

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Fernleigh Care Home 37 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW Lead Inspector Lesley Allison-White Unannounced Inspection 29th May 2008 09:30 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 Fernleigh Care Home DS0000070934.V365398.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. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernleigh Care Home Address 37 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW 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) 01530 414755 01530 414755 Avvsim Care Ltd Elaine Sparks Care Home 27 Category(ies) of Dementia (27), Dementia - over 65 years of age registration, with number (27), Mental disorder, excluding learning of places disability or dementia (27), Mental Disorder, excluding learning disability or dementia - over 65 years of age (27), Old age, not falling within any other category (27), Physical disability (5), Physical disability over 65 years of age (5) Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are with the following categories: Old People, not falling within any other category - Code OP Dementia - Code DE and DE(E) Mental Disorder, excluding learning disability or dementia - Code MD and MD (E) Physical Disability - Code PD and Code PD (E). The maximum number of service users who can be accommodated is: 27. 16th June 2006 2. Date of last inspection Brief Description of the Service: Fernleigh Care Home is situated in the west of the county of Leicestershire, and is close to the local shops and parks of Ashby de la Zouch. The home provides accommodation for older people either with or without a physical disability and/or a mental disorder. Part of the home is a converted older property, with the addition of a new extension. This has resulted in some of the rooms having en-suite facilities. The majority of the bedrooms are single, with four shared rooms also available, many of the bedrooms having views of the garden. There is a choice of lounges where individuals can relax, a dining room and many of the bedrooms have views of the garden. The mature gardens contain a range of mature trees and shrubs that fits in well with the rest of the residential properties in the area. The Statement of Purpose sets out the aims and objectives of the home, which includes the Service Users Guide. This information is available on request. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 5 A copy of the most recent inspection report is available on request. A copy of the Commission for Social Care Inspection (CSCI) registration certificate and Employers Liability of insurance certificate is displayed in the entrance to the home. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. The home provides care for up to twenty- seven people. On the day of inspection there were twenty- five people living at the home. One person was in hospital. The inspection took over six hours to complete. Preparation included examining inspection records and looking at the service history. This aided the inspection process by providing background information. Discussion was held with five people who lived there. Two people had memory problems and indicated how they felt when asked questions. The primary method of inspection used was “case tracking”. This involved speaking with the people who use the service provided, looking at two peoples care plans and making observations. (Care plans are records about the care or support provided for an individual). All the required key standards were inspected during this visit. New requirements were made at this inspection. The Registered Manager assisted during the inspection. What the service does well: At both entrances to the home there is a notice board where visitors are asked to sign in and out. It is easy to see and use. This is used for the purposes of fire safety. Staff who spoke with the inspector was aware of adult protection issues and felt that they would be able to protect and manage the safety of the people receiving care from them. People who spoke with the inspector also confirmed that if they had any concerns they would talk to family members or staff for their help. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 7 People living at the home said they felt they were treated well and observation of interaction between the people who lived at Fernleigh and staff appeared relaxed and friendly. The newly Registered Provider sent quality assurance monitoring forms to the people living at the home in December 2007 as part of their management quality review. Written plans as to how they will manage the different issues are also documented. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fernleigh Care Home DS0000070934.V365398.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 Fernleigh Care Home DS0000070934.V365398.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals who decide to move into the home will have their needs assessed and assured that these will be met. EVIDENCE: Short stay breaks are offered at the care home to anyone who needs this within the registration category. People who spoke with the inspector did not remember much about their assessment process but both people said that they were happy at the home. In place is a care plan and assessments for the provision of care and support provided. The Statement of Purpose sets out the aims and objectives of the home, which includes the Service Users Guide this information, is available on request. A copy of the most recent inspection report is available on request. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 10 A copy of the Commission for Social Care Inspection (CSCI) registration certificate and Employers Liability of insurance certificate is displayed in the entrance to the home. Standard 6 intermediate care is not offered at this home. Fernleigh Care Home DS0000070934.V365398.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ health is monitored and appropriate action is taken. EVIDENCE: Basic risk assessments are in place to show how care is to be delivered, which promotes the health and welfare of the person in care and that of staff. Policies are in place to assist practice. Copies of the most used and helpful policies are displayed on a notice board near the kitchen area of the home. Health care is monitored, with outcomes being recorded in peoples’ records by staff on an individual basis. Specialists attend to individuals when they need this. This includes access to the General Practitioner (GP), Chiropodist and District Nurses and Opticians on a regular basis. People who spoke to the inspector said they felt they were treated well and the interaction between the people who lived at Fernleigh and staff appeared relaxed and friendly. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 12 Four people’s medications were checked. A separate controlled drugs book is used and two signatures are entered when the drugs are given. This is good practice. Eye medications were seen in the food fridge stored in the kitchen in an uncovered plastic box. A requirement will be made for the safe storage medications. The medications are administered directly from the blister packs supplied by the pharmacy. There is no medicine trolley. The inspector did not witness the administration of medicines on this occasion and cannot comment on the safety of the procedures of administration by the staff at this home. The provider feels that the system that is operated is safe and that the home is well supported by the local pharmacist. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home find that their lifestyle mostly matches their expectations and feel comfortable in their surroundings. Meals are provided that appear nutritious. EVIDENCE: External entertainers visit the home twice a month where singing songs is one of the activities and the Registered Manager said that people living at the home enjoyed these occasions. The staff provides some activities in the form of bingo or pampering sessions including nail care. People who spoke with the inspector said that they would prefer to have more to do on a daily basis. Details of social care information in the care plans exists but may not always be used to plan activities with individuals. The home does not employ a specific member of staff to provide activities at this moment in time. The Registered Manager explains that this has been tried before and did not prove successful. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 14 At both entrances to the home there is a notice board where visitors are asked to sign in and out. It is easy to see and use. This is used for the purposes of fire safety. People who spoke with the inspector felt that they were able to maintain contact with their families. Visitors are welcome to the home at any reasonable time and are invited to make their own drinks from the kitchen area. In one of the people who the inspector case tracked it was noticed that information had been obtained from the relatives to enhance the quality of life for the individual such as past interests, however this information was not used as part of the care planning and did not support the care offered. This person now suffered with dementia and may have benefited from taking part in an activity that they had previously enjoyed and were familiar with. However, the Registered Manager feels that it is no longer appropriate for this person to do this activity due to failing eye- sight and the latter stages of the illness. People who spoke with the inspector felt that they made choices such as when they went to bed or when their visitors could visit or see them. A meal board is displayed in the dining room. This should help people with dementia to remember the meal that they will eat. A lunchtime meal was observed. The meals were served on small and large plates. The Registered Manager explained that the staff assess the individual and assess the portions accordingly. On a table with four women one person said that they rarely got offered more and another said that if they asked the staff would give it to them. Another person who was unable to ask was assisted to have another helping but may not have asked for herself normally. All the people who spoke with the inspector said that they enjoyed the meals provided at the home. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has procedures for dealing with complaints and protection. The people living at the home and the staff knew who to go to and what to do if they had a complaint. This gives protection to the people who live at Fernleigh. EVIDENCE: The Commission for Social Care Inspection (CSCI) has not received any complaints about this service since last inspection report. The Registered Manager has received a complaint. It had been dealt with. Staff who spoke with the inspector was aware of adult protection issues and felt that they would be able to protect and manage the safety of the people receiving care from them. People who spoke with the inspector also confirmed that if they had any concerns they would talk to family members or staff for their help. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Fernleigh are provided with a safe, hygienic and comfortable environment. EVIDENCE: The home is spacious due to the extension. It is a homely environment. The Registered Manager explained that different parts of the home are undergoing redecoration to improve it further. Some bedrooms have been re-decorated. The outside garage has been removed and the people who live at Fernleigh and their relatives (through a quality review of the service questionnaire) have made suggestions as to how they would like the new space to be used. Some relatives have volunteered to help with any proposed changes. The Registered Manager explained that all suggestions are considered. The home although untidy in parts is kept clean, pleasant and hygienic. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Provider has a recruitment procedure, which when fully implemented will further protect the people living at Fernleigh. EVIDENCE: Staff files were checked and evidence of relevant training was seen. There were certificates for courses such as Moving and Handling, National Vocational Qualification (NVQ) level 2 or above in care, Basic First Aid or Emergency First Aid, Food Hygiene and Vulnerable Adults Training. The Registered Manager explained that the numbers and skill mix of staff were sufficient to meet the needs of the people who received care at Fernleigh. Improvements in the area of recruitment practices are required. Two staff files were inspected. The application form was missing from them. Some recruitment practices were historical. This is registered as a new service however; the staff is inherited from the previous business. A recommendation will be made to ensure that the Registered Manager will now re-check all the staff records to ensure that they comply with good employment practices. Both staff records had Enhanced Criminal Records Bureau (CRB) checks in them. In this way the people living at Fernleigh are supported and protected by staff competent to do their jobs. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is managed by a person who is fit to be in charge. The home is run in the best interests of the people who live there. Individuals’ financial interests are safe guarded. The health, safety and welfare of people who live at the home and staff are promoted and protected. EVIDENCE: The Registered Provider and Registered Manager are new managers to Fernleigh care home. The newly appointed Registered Manager is familiar with the people who live at Fernleigh and the staff having worked in a different capacity at the care home before the changes. The position of deputy manager has a shared job status and two staff members offer support to the manager in this way. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 19 The Registered Manager said that the health and safety aspects of the home were up to date. There was evidence of Regulation 26 visits from the Provider. These are visits that the Provider must make to ensure that no problems are left unresolved in the management of the home. The Provider sent quality assurance monitoring forms to the people living at the home in December 2007 as part of their management quality review. Written plans as to how they will manage the different issues are also documented. Individuals are invoiced for small items such as hairdressing each month. Individuals are encouraged to keep their own monies or assisted to do so by their families wherever possible. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 20 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 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 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement In 2007 the law changed. All care homes, whether providing nursing or personal care, must now keep controlled drugs (CD) in a controlled drugs cupboard. In brief, the requirements for CD storage are: • • • Timescale for action 31/08/08 metal cupboard of specified gauge specified double locking mechanism fixed to a solid wall or a wall that has a steel plate mounted behind it fixed with either Rawl or Rag bolts. 2 OP9 Regulation 13 (2) 1. In accordance with the Care Homes Regulations 2001 Act. The registered person must make arrangements for the safe administration of medicines prescribed for the people they care for. This includes eye medications. DS0000070934.V365398.R01.S.doc 31/08/08 Fernleigh Care Home Version 5.2 Page 22 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 Refer to Standard OP12 OP29 Good Practice Recommendations Where details of social care information in the care plans exist it could be used to plan activities with individuals. The Registered Manager should now re-check all the staff records to ensure that they comply with good employment practices. Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Fernleigh Care Home DS0000070934.V365398.R01.S.doc Version 5.2 Page 24 - 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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