Inspection on 26/02/08 for Fernwood Court

This inspection was carried out on 26th February 2008.

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

Fernwood Court 21/06/06

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

CARE HOMES FOR OLDER PEOPLE Fernwood Court 300-310 Wolverhampton Rd West Bentley Walsall WS2 0DS Lead Inspector Wendy Jones Unannounced Inspection 26th February 2008 11:30 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 Fernwood Court DS0000066372.V358510.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. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernwood Court Address 300-310 Wolverhampton Rd West Bentley Walsall WS2 0DS 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) 01902 604200 fernwoodcourt@schealthcare.co.uk Southern Cross Healthcare Facilities Ltd Ms Karen Linda Badger Care Home 59 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (50), Mental disorder, excluding learning of places disability or dementia (8) Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the staffing levels agreed by the Responsible Individual and returned to CSCI in a letter dated 6 June 2005 are not reduced without prior consultation and agreement with the CSCI. That proposals are received from Southern Cross Healthcare Facilities Limited in respect of unitising the home within fours weeks of the date of registration. That the seven younger adults with mental health needs (MH) are found alternative placements within fours weeks of the date of registration. That the variation granted on the 13 September 2005 for one female service user who is 57 years and has dementia will only be for the lifetime of that service user and whilst the home is able to meet her needs. That the variation in respect of mental disorder (MD) granted on the 14 September 2005 will be for the lifetime of those five identified service users and whilst the home is able to meet their needs. That the maximum occupancy of the home is 59. 5. 6. Date of last inspection 21 June 2006 Brief Description of the Service: Fernwood Court is a purpose built, four storey building. Southern Cross Healthcare Services Ltd has privately owned the home since June 2005 since which time it has changed its name to Fernwood Court. The care home can accommodate up to 59 older people with dementia requiring personal care. There are communal rooms and assisted bathrooms on each floor. A passenger lift provides access to each floor. The home has a laundry and kitchen situated on the ground floor. The home has an enclosed garden at the rear of the building and a large car park at the side. All service users’ bedrooms have en-suite facilities. The fee range for the service is recorded in the resident guide as £360.27 plus top up £11.62 to £480. There is an additional charge for chiropody and hairdressing that are not included in the homes fee. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use the service experience good quality outcomes. This was a key inspection site visit of this service undertaken on 26 February 2008 and included formal feedback to the manager, deputy manager and operations manager. In total the visit took approximately 09:00 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 21/06/06 have been acted upon; looking at information the service provides for prospective residents, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, staff and residents were spoken to during the site visit and a brief tour of the building was undertaken. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to residents, relatives and any professional that has involvement in the service. Two staff surveys have been returned along with one health professional survey, two residents’ surveys and one relative’s surveys. The main points from this information are included in this report. Since the key visit the provider has confirmed that action has been taken to ensure that errors in financial records have now been rectified following a lengthy period of investigation and are now satisfied that financial records are accurately maintained. The manager has written to confirm this and has also stated that the shaft lift has been repaired and is now working properly. This followed assertive representation by herself and the organisation to their contractor. What the service does well: Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 6 The evidence of this visit is of a service that is committed to providing good quality outcomes for residents. The manager has strong leadership skills and demonstrates an enthusiasm for ensuring that the service is open and continues to improve. The standard of record keeping is high and there is evidence that the service has learned from past experiences and complaints. The services commitment to meeting the diverse needs of residents should be applauded. 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. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 7 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 Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 8 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): 1, 3 and 6 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People who may use the service can be sure that their care needs are properly assessed prior to them being offered a placement. This means that they can be confident that the service can meet their needs. EVIDENCE: The service has both a Statement of purpose and Service user guide these are on display in the main foyer of the home. On inspection it was noted that there is a need to ensure both documents are reviewed so that that they give an accurate account of the service and its’ management and staff team. The service user guide should also include the range of fees and charges for the service. This information has now been provided. The manager has confirmed that all residents have a copy of the resident guide and statement of purpose in their bedrooms. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 9 A sample of care files show that the service has robust admission procedures that include thorough assessment of the individual in their place of residence where possible. The manager confirmed that even in an the event of an emergency referral she will visit the individual to ensure that an assessment is carried out to confirm that the service can meet their needs. The service does not provide intermediate care beds. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 10 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. People who use the service can be confident that their health needs are known, assessed and that there are plans in place to support them. This mean that they can have confidence that the service will act promptly to ensure that appropriate support is accessed should there be any deterioration in their health needs. They can also be sure that the service has good systems and procedures in place for the management, administration and storage of medication, and that all staff who administer medication are trained to do so, this ensures the residents health and well being. EVIDENCE: Information in a sample of care plans show that thorough assessments of need are in place and where necessary care plans and risk assessments have been developed. The service has ensured that these are reviewed monthly and staff have carried out at least a 6 monthly formal review with the individual and/or their relative. The manager stated that she hoped that this type of review Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 11 would take place at least 4 times per year. Where residents have not been involved in a review the manager has stated in recent correspondence that, “ where residents tend to find difficulty participating in this due to their state of health and lack of concentration. Relatives or advocates are invited to participate. To further support this where family members/advocates have chosen to not attend review we will confirm the outcome to them in writing.” The service uses a nursing model of assessment that is simple and effective and can be adapted to the needs of the service or individual. Health care needs have been assessed and there is evidence of much good practice in the records. The care staff ensure that health appointments and preventative health checks are arranged. A district nurse visits the home very regularly. At the time of this visit, 4 residents have pressure sores, two of which are hospital acquired. Records relating to this are detailed, regularly evaluated and follow good practice recommendations. Records show that residents are supported to receive services from health professional and to attend preventative health appointments. Since the last inspection site visit the service has reported two incidents when the medication administration procedures hadn’t been followed correctly. The manager took immediate action to safeguard residents and made safeguarding referrals. Also since the last inspection the service has made considerable efforts to ensure to ensure that medication procedures are robust, introducing daily checks on the running totals of medication and audits to ensure that medication is signed for properly. From a random sample and audit of the records this is found to be effective. Room and fridge temperatures are recorded daily to ensure that any problems are identified promptly. The medication stock room could be more organised, but this does not affect the outcome for the people who use the service. Staff responsible for the administration have received training, and the manager confirmed that assessments of competence are undertaken. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 12 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 (adequate). This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their cultural and dietary needs will be met, but can not be sure at the time if this visit that they will have the opportunity to be regularly involved with activities in the home. EVIDENCE: Since the last key inspection the service has recruited a full time activities coordinator, and there is evidence that efforts are being made to provide suitable activities for residents. This is very much a work in progress. In the main foyer of the home the co-ordinator has details of the planned activities for the week these are broken down into four or five sessions per week. In the care files the service has also introduced an activity record that is completed by the coordinator. A sample of files show that some residents are spending a lot of time in passive activities such as watching TV and listening to music, it is accepted that the co-ordinator is fairly new in post and also noted that the manager gave a commitment to developing this area. The exception to this is the younger adults unit where residents live a reasonably active and independent lifestyle, one resident said, “ I go out and Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 13 catch the bus by myself.” Two residents from this unit had been shopping with a carer during the inspection site visit. One resident on the unit was engaged in putting together a jigsaw; another was involved in knitting. In respect of the service meeting the diverse needs of its resident group, the manager said that every effort was made to ensure that, where stated residents religious, cultural and social needs are respected. On one example a resident whose first language is not English has been allocated a key worker who is fluent in her language to ensure that communication is not an area of concern. The AQAA states, “We have a catholic priest come in once a month to give holy communion, we have staff who can speak different languages. I have changed the seating around the communal lounges to allow relatives to be more private when visiting there relatives. We have a hospitality room which is available for private and confidential discussions.” A discussion with the catering manager confirmed that since the last inspection the mealtime routine has improved. The service now offers two sittings; this is reported to have reduced the levels of anxiety of some of the residents, as the dining room is not crowded or as noisy as it was. A small group of residents were observed eating their evening meal, those that needed assistance is given one to one support by carers. The atmosphere was relaxed and pleasant. The catering manager provided evidence of good practice in relation to the record keeping and checks undertaken by the catering team. A three-week menu is available and the meal choices of the day are displayed on a notice board in the main dining room. She also stated that they hoped to produce a pictorial menu for those residents who would benefit from this. In the staff survey’s a comment about the food said, “ The food could be improved, I don’t think they have a balanced diet. There is a poor choice of breakfast and frozen vegetables are used when they could have fresh and the tea time choices are poor.” Residents said that they were happy with the food, that they had a choice and on the younger adult unit can get involved cooking their own meals if they want to. An inspection of the kitchen stock room showed that the service does have fresh vegetables delivered and also uses frozen vegetables. The menu’s show that at least two vegetables are served with the main meal of the day. In relation to breakfast and teatime choices. The manager and catering manager stated that usually residents are offered choices of cereal or porridge, toast and fruit juice for breakfast but can have a hot choice on request. For the evening meal the records show that there is a choice of a hot or cold meal on the menu but other alternatives can be provided. Sandwiches are offered at suppertime. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 14 The service currently provides special diet for those residents who have differing needs these include low fat, low sugar and soft diets. They also demonstrated that where residents have a differing cultural background from the main resident population, they have made considerable efforts to obtain and or cook suitable meals for them. The manager said that she had even brought in special meals. This was evidence of this from the food stocks seen. Fernwood Court DS0000066372.V358510.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): Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that any concerns they have about the care they receive are taken seriously and investigated. They can also be confident that action will be taken to protect them from the risk of abuse, this should afford them confidence that the service is committed to ensuring their best welfare. EVIDENCE: The service has a complaints procedure that is on display in the home and is included in the resident guide. Residents confirmed that they felt able to make a complaint if they needed to. Since the last inspection we have received 3 complaints, 2 of which have been referred to the provider for investigation we are also aware of 3 safe guarding referrals that have been looked into. The service does keep us informed of events in the home and has; where necessary made changes to its procedures to be sure that the welfare of residents is protected. The manager holds records of all complaints received by the home and has evidence of how they have been managed. A service user survey confirmed that the individual knows who to go to if they have any concerns and a complaints procedure was on display in the main foyer of the home this is included in the service user guide. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 16 In addition we are informed of any incident in the home such as accidents and falls, there have been a number of these some of which have resulted in serious injury to the individual. During the period from January 2007 we have been notified of 23 accidents in the home, of which 17 have been falls, 9 residents have sustained injuries and 9 others have been diagnosed with a fracture. Care records show that the service has introduced risk assessments for each individual regarding falling and also regarding injury to the person particularly if it unexplained. The procedure for staff to follow is displayed at all the nurse stations in the home. We have received an anonymous contact re concerns about staffing levels, manual handling practice, pressure area care, medication training and induction. This was passed to the provider to investigate. We also received a second contact re manual handling practice. This matter was looked into during this site visit and has been included in a safeguarding referral. Of the 33 care staff, 5 have yet to receive manual handling training or up dates, the manager has agreed to ensure this happens quickly. The contact also raised concerns about the quality of the training. The manager should inform us of the content of the training and provide evidence that the staff team are assessed as competent. In the AQAA, the manager has said, “In supervision I give staff members some scenarios of a complaint or a form of abuse, and ask them how they would deal with the situation. I document this on the supervision form. This ensures they are mindful at all times, and understand the different concepts.” Since the last inspection the service has reported an issue of monies going missing, the matter has been investigated. The manager said that the company has repaid all monies owed to residents. During this visit 2 service users were identified who do not receive their personal allowance, it was reassuring to hear that the manager has referred both issues under safeguarding procedures and that if the individuals need monies the service will ensure that they are not disadvantaged because of this. The administrator wasn’t sure of the procedure for requesting this money but the manager gave her assurance that she was able to purchase items on their behalf. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the environment in which they live is comfortable and well maintained. This ensures that they can be confident that it is suitable for its purpose. EVIDENCE: This site visit did not include a detailed inspection of the environment but from observation it is noted that the home is well maintained, pleasantly decorated, homely and clean. Considerable efforts have been made to provide an environment that aids the orientation of residents with dementia. This includes, individually coloured bedroom doors, letterboxes and numbers on their bedroom doors, appropriate signage to aid the orientation of residents and also the creative use of colour. Sensory boards have been put up in corridor that aid memory recall of everyday items as well as having different Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 18 textures for residents to touch and feel. Different corridors have different themes, to aid orientation. All rooms are for single occupancy and have en-suite facilities; there is sufficient communal space to meet the needs of the resident group. More work should be done to ensure that resident bedrooms are personalised. The manager has a planned refurbishment programme that she is working to which included further development of the home for the benefit of those residents with dementia. Information in the AQAA, states. “The home is kept to a good standard of hygiene at all times, We have had window restrictors placed on all windows above ground floor for a safer environment for the service users. Any obstructions are removed where it could implicate a hazard of tripping or slipping. Repairs are done promptly. All safety checks are carried out within the legal requirement. Hold Monthly Health & Safety meetings.” Standards of hygiene and maintenance are good, and residents said that they are happy in their environment. The shaft lift connecting all floors wasn’t working during the site visit the manager was dealing with this. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 19 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 (good). This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they receive support from a staff team that has been appropriately recruited and has the skills to meet their needs. This should give them confidence in the service. EVIDENCE: The home currently employs 45 staff. Of who 33 are care staff. Staff are deployed as follows: 8-9 staff 7.30am-2.15pm 8-9 staff 2.00pm-9pm 4-5 staff 8.45pm-7.45am Additional staff provided for the younger adults unit of 1-2 staff during the waking day and 1 at night. The managers’ hours are additional; the deputy also has some additional hours. Support is provided from catering and domestic teams, from the office administrator and the maintenance person. Staff meetings are planned every 3 months and weekly in house training sessions are arranged. Minutes of each meeting are given to each member of staff. The service has its own manual handling trainer. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 20 Of the total staff team of 45 only 7 have yet to undertake NVQ training, it is the intention of the service that all staff will be trained to NVQ level 2. 7 staff have NVQ level 3 and the deputy manager is to enrol on the level 4 course. Staff training records show that the manager is up to date with the training needs of the service and provide evidence of the services commitment in terms of valuing staff and to provide a fully trained workforce. All the care staff team has received training in the management of challenging behaviour a requirement of the last report. All care staff team has received training in the safe use of bedrails. The service has a robust induction system; staff confirmed that they had received a satisfactory induction. Recruitment records are satisfactory with evidence provided that all pre employment checks are undertaken. The manager was asked to ensure that all staff are involved with fire drills and confirmed from her records that the majority have received fire training or recent updates, there is a programme of updates in place for all training. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 21 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 who use the service can be sure that the management and administration of the home is based on openness, and has effective quality assurance systems developed by a qualified and competent manager. This gives them confidence that the service can meet their needs. EVIDENCE: The manager has completed the NVQ Level 4 in care and the registered care managers’ award; we approved her in June 2007 as a fit person to manage a care home. Records evidencing her qualification were seen during this visit. Arrangements for the supervision of staff are satisfactory the manager provided evidence that she has plans individual staff supervision every 2 months, the records show that all sessions but for 4 are up to date. And 98 of staff have received an annual appraisal. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 22 The management team included Ms Badger and her deputy, there is a senior team leader and a 13 senior care staff. A catering manager and administrator support them. In the Statement of Purpose it said that monies above £500 would be saved in an individual account but other monies would be stored in a collective account that did not accrue interest. A check of the financial records held by the service shows that, all transactions made on behalf of residents are recorded have receipts that can easily be traced and show the current balance. A check of the float records against the monies actually in the home showed that the records are not accurate. The manager identified this as an area she was aware of and related to the problems when monies went missing. (see complaints and protection). We do not understand why this remains an issue and have spoken to an Operational manager of the organisation. We have asked that the evidence that this matter has been resolved be forwarded to us. Quality audits are carried out on a monthly basis. Surveys are circulated to service users and families, other surveys are sent to other interested parties. An analysis of the outcome of these surveys is available in the main foyer of the home. In addition a representative of the organisation carries out monthly monitoring visits to the home and action plans are produced from the outcome of these visits. The manager provided evidence that she is working on an annual development plan for the home. Information in the AQAA confirms that all equipment in the home is serviced regularly and maintained. At the time of this visit the shaft lift wasn’t working and had been out of action since the 21/01/2008. We had not been informed of this prior to the inspection. The manager was asked to ensure that any risk assessments necessary are carried out this particularly relates to care and ancillary staff who have to carry items up the stairs until the situation is resolved and any resident who’s mobility means that they are not able to leave the home because of this. The manager should also inform the fire safety officer. In discussion with the manager during and following this visit, there is evidence that she has acted upon the recommendations made. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x 3 x x 4 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 2 2 3 X 3 Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. 4. 5. Refer to Standard OP12 OP7 OP15 OP38 OP35 Good Practice Recommendations The service should continue with the plans to provide residents with more activities both in and out of the home. All residents and or their representatives should be involved in care plan reviews The service should continue in its aim to provide residents with a menu that is in a format that is more easily understood. The service should ensure that the shaft lift is repaired and fully functional. The registered person should ensure that the records relating to finance are accurately maintained at all times. Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Fernwood Court DS0000066372.V358510.R01.S.doc Version 5.2 Page 26 - 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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