Inspection on 10/12/07 for Fethneys - Living Options

This inspection was carried out on 10th December 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Fethneys - Living Options 9 Farncombe Road Worthing West Sussex BN11 2UK Lead Inspector David Bannier Unannounced Inspection 10th December 2007 09:30 Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fethneys - Living Options Address 9 Farncombe Road Worthing West Sussex BN11 2UK 0207 802 8200 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) info@LCDisability.org The Leonard Chesire Foundation Mr Marcus Peter Richards Care Home 10 Category(ies) of Physical disability (0) registration, with number of places Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Physical disability (PD). The maximum number of service users to be accommodated is 10. Date of last inspection N/A Brief Description of the Service: Fethneys is a care home, which is registered to provide personal care for up to ten service users in the category physical disability (PD) who are between the ages of 18 to 65 years of age. The service has been set up to provide care and accommodation for younger adults who are planning to move on to independent living. It is a detached property, which has been extended and adapted for its current use, and is located close to the centre of Worthing. The property is a two storey building providing private accommodation to service users in single bedrooms located on the ground and first floors. Each bedroom includes ensuite toilet and shower facilities specifically designed to be accessible for residents using wheelchairs. Communal accommodation is made up of a lounge and a kitchen/dining room located on the ground floor. Fee levels currently range from £1250.00 to £1449.00per week. Personal items such toiletries, chiropody and hairdressing is not included. The registered provider of this service is The Leonard Cheshire Foundation. The Responsible Individual acting on behalf of the organisation is Mr Peter Bray. Mr Marcus Richards is the registered manager and is responsible for the day to day running of the care home. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection since this service was registered with us on 29th June 2007. Fethneys has replaced a service owned by the same registered provider that has now closed. The manager and the majority of residents have transferred to the new premises. The inspection has followed the Inspecting for Better Lives methodology and is called a key inspection as it assesses those standards determined by the Commission as key standards. This inspection will also determine the frequency of inspections hereafter. The registered provider returned an Annual Quality Assessment Form (AQAA) prior to the inspection. Residents were sent surveys by the Commission entitled “Have Your Say.” These are designed to enable residents, relatives and other stakeholders to give their opinions about how the care home is being run. We assisted by a resident, known as the link resident, who helped us by giving out surveys and collecting them from other residents. Five surveys completed by residents were returned to us. The information received from these documents will be referred to in this report. A visit to the care home was made on Monday 10th December 2007. This was an unannounced inspection. This means that the manager and staff had no notice of our intention to visit. We spoke to two residents during our visit in order to learn about what it is like to live at this care home. We also spoke to four staff who were on duty in order to gain a sense of how it was to work at the care home. We also viewed some of the accommodation and observed care practices. Some records were also examined. The visit lasted approximately eight hours. Mr Richards was present and kindly assisted us with our enquiries. What the service does well: Fethneys provides personal care, accommodation and services designed to prepare residents for independent living in the community. Residents are encouraged to be involved in daily chores and in the day to day running of the care home. They are also supported in making decisions about their lifestyles. Staff are provided with support and training on order to facilitate residents’ decisions. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 6 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. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ individual needs and aspirations have been assessed. EVIDENCE: Three residents were identified for case tracking purposes. Documents and records seen confirmed that the needs of the identified residents had been appropriately assessed. Assessments were comprehensive and covered the following areas: communication, mobility, nutrition and hydration, hearing and sight, continence, sleeping patterns, medication, personal hygiene, and any requirements regarding specialist equipment. Each section of the assessment included room for comments made by the prospective resident or their advocate. Two of the three residents identified had transferred from the care home that has now closed. Surveys returned by residents confirmed that they had been asked about the move and had been provided with all the necessary information they needed before deciding to move into Fethneys. Some residents had helped with the design and layout of the new care home to Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 9 ensure it is accessible and fit for purpose. One resident commented, “I was involved with the layout and design of the house before I moved in.” Discussions with staff on duty confirmed they had been made fully aware of the needs of each resident and how they should be met. Information supplied by the registered provider confirmed that, “Fethneys is a new purpose built facility in the heart of Worthing. It allows young disabled people to gain independence People are admitted to Fethneys after a comprehensive pre admission assessment and a visit to Fethneys.” Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have been consulted when care plans have been drawn up. Residents are encouraged to make choices about their own lifestyle, with support where needed. Residents have been involved with day to day decisions about the running of the care home. EVIDENCE: Individual care plans have been drawn up with each resident. However, there were instances when care needs identified by the assessment process has not been transferred into care plans. This means it is not clear if these needs are being met. There were also instances when care plans do not include clear Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 11 information or guidance to staff with regard to the action they should take to ensure care needs have been met. This means it is not always clear how identified needs will be met. We discussed this with the manager who agreed to look carefully at care plans to ensure this information is included. Discussions with staff on duty confirmed that despite the lack of information in care plans, they have been provided with good information about the individual needs of each resident and the actions to be taken by them to ensure they are met. Information supplied by the registered provider confirmed that, “We involve each service user in the writing of their care plan and ensure that these documents highlight individual goals and aspirations.” Surveys returned by residents confirmed that they can make decisions about what they do each day. However, this can sometimes be limited by the availability of staff to assist residents. One resident commented, “It depends if there is a member of staff to take me.” Residents are expected to negotiate with each other for staff to provide them with the assistance they require. We found evidence that the manager meets frequently with residents to discuss such issues. Minutes have been kept of such meetings to ensure there is a record of discussions and agreements that have been made. Information returned by the registered provider confirmed that, “We promote and facilitate choice and independence. We encourage residents to take calculated risks.” Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in appropriate activities. Residents have been encouraged to become part of the community. Residents have been supported in forming/maintaining personal and family relationships. Residents have been provided with a healthy, varied and appropriate diet. EVIDENCE: Residents do not have an individual activity programme for each day. The manager informed us that this would not be appropriate, given that residents are working towards moving out of Fethneys into the community. Residents are expected to make their own decisions regarding activities depending on Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 13 lifestyle decisions they have made. We were informed that residents are involved in a range of activities. These include attendance at courses run by a local college designed to provide the skills and knowledge residents will require when moving onto independent living and also adult numeracy and literacy courses; attendance at a local day centre; swimming and bowling. Some residents are involved in attending and running forums run by the Leonard Cheshire Foundation designed to give residents a voice within the organisation and to represent the group within in the care home. In addition to this residents told us they enjoy shopping, visiting local pubs, cafes and clubs. On the day of our visit residents had planned to go out Christmas shopping for gifts, decorations and Christmas trees. Residents who completed surveys confirmed they can do what they want during the day. Information supplied by the registered provider confirmed that, “Our whole aim is to enable service users to gain independent living skills. We encourage service users to attend college. We try to ensure that service users make their own decisions regarding social and leisure activities in the local community. We respect people’s privacy and try to avoid having institutionalised routines.” We spoke to a group of staff who were on duty. From discussions and observations of care practices, it was clear that staff respect and promote the privacy and dignity of residents. Staff support residents in maintaining appropriate family and personal relationships. The registered provider has drawn up policies and procedures for the manager and his staff to follow to ensure vulnerable adults are protected when developing personal relationships. The registered provider is in the process of revising and, where necessary, amending them to ensure they are in line with current legislation and good practice guidelines. The registered provider will also be providing staff with further training in these areas to ensure they are aware of the implications of current legislation. We were informed that residents meet together for the main meal that is provided in the evening. One resident takes responsibility for this including deciding on the meal to be provided and shopping for the ingredients. Staff on duty will them cook the meal. Residents are also provided with a budget so that they can cater for themselves. Information supplied by the registered provider confirmed that, “We provide a main meal which is cooked by support workers. The menu for the week is chosen by a different service user, who is also responsible for going out shopping. We provide a small food allowance to allow service users the opportunity to make decisions about their own snack meals.” We were provided with copies of copies of menus for the past few weeks. This conformed that residents have been provided with a varied and wholesome diet which is appropriate for their needs. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support and personal care provided takes into account the wishes and personal preferences of each resident. The physical and emotional health care needs of residents have been met. Staff deal with medicines in a way that protects and supports residents. EVIDENCE: There was clear evidence that care plans have been drawn up after consulting with residents. This means residents wishes and choices are included. They also have a major say in the way personal care is provided to them and the lifestyle they choose to follow. Residents are expected to negotiate with each other when choosing what time they get up and go to bed, or if they wish to go out. Records seen included a clear record of medical appointments made to health care services such as GP’s, opticians and dentists. This also includes a record of the outcome of the consultation and, where necessary, the treatment to be provided. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 15 Surveys returned by residents confirmed that they can do what they want to do during the day, in the evening and at the weekend. One resident commented, “Yes, we can do what we want to do but we need to plan to see if it is possible to do this. If we are very short of staff we cannot go out in the evening.” Information supplied by the registered provider confirmed that, “We provide a high level of personal care at a flexible time. We provide guidance on healthcare issues and direction to appropriate advice.” We noted that medication has been appropriately and securely stored. The registered provider has set up an appropriate method for administering and recording medication that meets the needs of residents. We were advised that only staff who have been appropriately trained are allowed to administer medication. Training records seen confirmed that staff have received in house training in the safe administration and dispensing of medication. We were informed that, currently two residents are considered to be capable of administering his or her own medication safely. However, we also noted that records seen were not always up to date. This means it is not clear if residents have received prescribed medication according to the directions of the resident’s GP. In addition, where medication has not been given, it is not clear why this is so. The registered manager agreed to look into to this to find out why records have not been kept up to date. As this directly affects the health and wellbeing of residents this has been made a requirement. This appears at the end of this report. Information supplied by the registered provider confirmed that, “We allow service users to self medicate where possible.” Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has set up a system for ensuring residents’ views are listened to. Residents are protected from abuse, neglect and self harm. EVIDENCE: Resident meetings are held regularly. Minutes of such meetings were available for us to see. The manager encourages residents to discuss any issues that can be sorted out before they become major concerns. A complaint procedure has been drawn up so that residents, their families and friends know how to make a complaint if they wish to do so. Surveys returned by residents confirmed they knew who to speak to about any concerns and how to make a complaint. They also confirmed that staff do listen to residents and, where necessary act on what has been said to them. Surveys returned by relatives confirmed that the service has responded appropriately if concerns have been raised with them. Information supplied by the registered provider confirmed that, “We have a robust complaints system with complaints/actions/outcomes monitored by a regional complaints coordinator.” We also informed that the registered provided had yet to receive a formal complaint since the service has been opened. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 17 Staff on duty confirmed they know how to identify different types of abuse and also know what to do if they witness a resident being abused. Training records confirmed that staff are provided with training about adult protection. The registered provider has also provided information that confirms appropriate policies and procedures are in place that are designed to protect vulnerable adults from harm. The registered provider also confirmed that, “All staff and volunteers undertake necessary training. All service users are provided with safeguarding adults and complaints leaflets.” Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have been provided with a homely, comfortable and safe environment in which to live. Residents have been provided with specialist equipment to enable them to maximize their independence. The home has been kept to a good standard of cleanliness and hygiene. EVIDENCE: Fethneys has been opened to replace another service which has closed. As part of the transfer process some residents helped with the design and layout of the premises to ensure it was completely accessible to residents with physical disabilities. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 19 We visited two bedrooms, one of which was empty, the lounge and the kitchen/dining room. Those areas of the home seen were presented in a homely and comfortable manner. The decoration and furnishings provided ensured residents live in a comfortable and safe environment. Residents have been able to personalise their own rooms. Colour schemes and soft furnishings have been chosen which reflect the personality and interests of each resident. Other items that residents have bought include posters and pictures, televisions, CD players, and personal computers. In addition we saw a range of specialist equipment that had been provided for residents. This included an electronically opening front door, a passenger lift, kitchen equipment such as sinks and work surfaces, ovens and electric sockets which can be accessed at wheel chair height, a dining room table which can be raised and lowered, specialist beds and mattresses, tracking and overhead hoists. We also viewed the kitchen and the utility room. These areas of the premises were fresh, clean and hygienic. Dedicated cleaning staff have been appointed to ensure communal areas of the premises is kept clean. Residents are expected to keep their own private accommodation clean and tidy. They are also expected to do their own laundry. Staff will support residents in these tasks where necessary. Comments made by residents in surveys were positive and confirmed the environment is kept fresh and clean. One resident commented, “I do try to keep my room clean.” Information supplied by the registered provider confirmed that, Each bedroom is well in excess of minimum requirements regarding space. All bedrooms have overhead ceiling hoists. The kitchen is accessible and service users are able to make drinks whenever they want.” Information supplied by the registered manager prior to this visit confirmed the registered provider has also taken appropriate steps to ensure the premises and equipment within the care home is safe for use. Gas and electrical appliances have been checked and maintained regularly. There is an internal system for staff to use to record and report any issues related to the maintenance of the premises to ensure any defects or repairs are dealt with. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 32, 34 and 35 Competent and qualified staff support residents. The home’s recruitment practices and procedures protect vulnerable residents. The staff team have met residents’ needs. EVIDENCE: We examined the recruitment records of four staff who have been appointed since Fethneys has been registered. All appropriate checks were in place to ensure vulnerable residents have been protected. We also met another member of staff who had recently been appointed. We were advised that, as part of their introduction to the service, this person was undertaking an induction programme that had been designed by the registered provider. This person would not start working at Fethneys until the induction had been completed. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 21 We looked at staff training records. They also demonstrated that newly appointed staff undertake structured induction training. This includes providing an understanding of the principles of good care practices and covers the promoting of residents’ rights, independence, choice and dignity. Training records also provided evidence that confirmed staff have been provided with mandatory training such as identifying and reporting abuse, fire safety, health and safety, moving and handling, first aid, care of medicines and food hygiene. Staff spoken to confirmed the training and induction training they had received. They also confirmed that they had received training in issues related to disability and equality. There was also evidence that demonstrated they receive regular support and supervision from a senior member of staff. Following observations of care practices and discussions with staff on duty we concluded they are skilled and knowledgeable in providing support and personal care to residents accommodated at this care home. Surveys returned by residents confirmed that staff do treat them well. One resident told us, “They are a good team.” We were also told that some residents were also involved in the process of interviewing new staff. Information supplied by the registered provider confirmed that, “All candidates are checked against CRB and POVA lists. All new staff undertake appropriate training. All staff receive supervision.” Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care home is well run and in the best interests of residents. The views of residents and their families are sought as part of any self – monitoring, review and development of the care home. The health, safety and welfare of residents and staff have been promoted. EVIDENCE: Mr Marcus Richards is the registered manager of this care home. As a result of the registration process he has demonstrated he has the necessary skills, Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 23 knowledge and experience to manage a service for younger adults with physical disabilities. The registered manager meets regularly with his staff team to discuss issues related to the service provided and the individual care needs of residents. This ensures the staff team are clear about what is expected of them and are aware of how the aims and objectives of the service should be implemented. We were provided with copies of a selection of meetings that have recently taken place. Representatives of the registered provider visit Fethneys each month to ensure this care home is being run in the best interests of residents. Reports of such visits were available for us to examine. Reports include details of discussions with staff on duty and with residents or observations of care and support provided. The registered provider has a quality assurance system in place. We were informed that Fethneys will be subject to this process on the first anniversary of its registration. The registered manager has developed a system for monitoring incidents and accidents, which have occurred in the care home. The appropriate agencies, including the Commission, have been notified of those incidents and accidents that are required to be reported. The purpose of the monitoring system is to review incidents to identify any areas where improvements can be made to ensure the safety of residents and staff has been fully protected. Training records seen confirmed that staff have been provided with training regarding health and safety issues, manual handling and food hygiene. This will ensure the safety and wellbeing of residents and staff. Information supplied by the registered manager prior to this visit confirmed the registered provider has also taken appropriate steps to ensure the premises and equipment within the care home is safe for use. Gas and electrical appliances have been checked and maintained regularly. There is an internal system for staff to use to record and report any issues related to the maintenance of the premises to ensure any defects or repairs are dealt with. Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 25 N/A 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 YA20 Regulation 13.2 Requirement When medication is administered to people who use the service it must be clearly recorded, to ensure that people receive the correct levels of medication. Timescale for action 07/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fethneys - Living Options DS0000070291.V354429.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!