Inspection on 16/06/05 for Fiennes House

This inspection was carried out on 16th June 2005.

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

Fiennes House 18/12/08

Fiennes House 09/01/07

Fiennes House 15/11/05

Fiennes House 19/01/05

Fiennes House 09/09/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Fiennes House Drakes Park North Wellington Somerset TA21 8TB Lead Inspector David Kidner Announced 16 June 2005 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 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 Stationary 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. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fiennes House Address Drakes Park North Wellington Somerset TA21 8TB 01823 661529 01823 662319 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) SeeAbility Mr Stephen Rowland Mudway Care Home 7 Category(ies) of 1. People aged 18 - 64 with learning disabilities. registration, with number of places 2. People aged 18 - 64 with physical disabilities. 3. People aged 18 - 64 with sensory impairment. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 7 persons in categories LD, PD and SI. Date of last inspection 19 January 2005 Brief Description of the Service: Fiennes House is registered with the Commission For Social Care and Inspection to provide personal care for up to seven people under the age of 65. It is registered in the categories of sensory impairment, physical disability and learning disability. The providers are See Ability. See Ability is a registered charity. The home has been purpose built and is situated close to all the amenities of Wellington. All bedrooms are for single occupation and five service users have full en suite facilities. Two service users share one assisted bathroom. The home is surrounded by well maintained landscaped gardens including a ‘sensory’ garden. The gardens are fully accessible for wheelchair users. In addition to the home there is an activity and resource centre adjacent to the home service users access. This is known as The Bill Cooke Centre. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Announced Inspection took place over one day (7hrs). The Inspector would like to thank the service users, registered manager and the staff team for making the inspector welcome at the home. The Inspector viewed all parts of the home, viewed records in relation to care and support plans, staff recruitment, health and safety and medicines records. The Inspector met all service users and was able to speak to three service users. One service user spoke to the inspector in more depth than others. Two staff were spoken to in private and the inspector was able to meet with one parent. The Inspector observed the staff team interacting with service users in a very professional, caring and sensitive manner. As part of the inspection process service user comment cards were distributed. In the main, the parents of the service users completed these. The feedback from the comment cards indicated that the service users liked living at the home, they felt well cared for, they felt safe, privacy is respected, food was good and activities are suitable. However, there was comment about activities being suitable when staffing levels prevailed. As a result of this inspection the home has one requirement for which an Immediate Requirement was issued at the time of the inspection and four recommendations. What the service does well: Fiennes House provides a safe, homely and service user friendly environment. All parts of the home are accessible to the service users. There are sensory gardens and other outdoor areas that are nicely presented including attractive water features. All bedrooms are of single occupancy and reflect individual preferences and needs. The home has many aids and adaptations to promote the independence of the service users. The home is due to be redecorated in the very near future. There are detailed care and support plans with risk assessments where needed. The care and support plans are reviewed on a regular basis with appropriate persons involved. All records were well maintained. Service users access a variety of health care professionals as and when needed. Parents report very good communication with the home and that they are kept informed. Parents are fully involved in the care and support plans. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 6 As well as service users accessing The Bill Cooke Centre for daytime activities, therapeutic sessions and education. It is pleasing to note that the home is exploring with the service users, appropriate college courses that may meet individual need. This is very encouraging as service users access mainstream educational facilities. The homes recruitment process is robust. Currently staff do not work at the home until an Enhanced CRB clearance has been obtained and they have completed their Induction Programme. What has improved since the last inspection? What they could do better: The home must ensure that the staff receive regular training in fire safety. It was noted that a number of staff have not received fire training since Induction. An Immediate Requirement was issued at the time of the Inspection. The Inspector acknowledges the commitment that the staff team make to provide social and leisure activities. However, the home should review staffing levels for evenings and weekends so that staff can offer and accompany service users to social and leisure opportunities at such times of the week. The Registered manager should consider replacing a washbasin in one identifies service user’s en-suite to provide better access to this area. The home should consider reviewing the menu to further promote healthy eating. The home should ensure that two staff signatures are obtained for service user’s financial transactions wherever possible and copies of bank/building societies are obtained for reference. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 7 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. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The Inspector was unable to make judgements on all of the above standards, as the last service user to be admitted to Fiennes House was in March 2001. The home is very well equipped to meet the needs of service users. EVIDENCE: There have been no new admissions since March 2001. However, the Inspector viewed two care plans and there was evidence that detailed assessments took place prior to service users being admitted to the home. Including the appropriate involvement of both families and advocates where needed. The Inspector viewed all areas of the home. The home is well equipped to meet the needs of the people living at Fiennes House. There are physical adaptations throughout, signage and individualised tactile references, adapted bathrooms and en-suites that provides an environment which maximises opportunities for independence. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 7 8 9 10 Service user care plans are user-led, detailed and are reviewed on a regular basis. Service users are encouraged to make decisions about their life and are supported and encouraged to be involved in the running of the home. Risk Assessments are conducted where needed. The home promotes confidentiality. EVIDENCE: The Inspector viewed two care plans. Both care plans were very well maintained, detailed, signed and dated. Reviews occur on a monthly and basis and are formally reviewed on an annual basis in a multi-disciplinary type review. A plan of action clearly sets out the needs identified and person/s responsible. There was evidence to demonstrate that the service user, their families and care managers are involved in the care planning process. The service users at Fiennes House are encouraged and supported to make choices in their everyday lives. The Inspector witnessed staff offering choices to service users in activities and for food and drinks. Day to day records are Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 11 kept of activities and opportunities. Signage and tactile clues throughout the home also aid choice and independence. Service users were observed to be ‘involved’ in the day to day running of the home according to their needs and preferences. At the time of the inspection the inspector witnessed service users being encouraged and supported in assisting in household tasks. Staff receive training in disability awareness to assist a ‘user-focussed’ approach. Each of the care plans viewed had risk assessments where needed. Risk assessments are in place regarding the use of bedsides in individual rooms. This has been addressed as requested at the last inspection. The home has policies in relation to access to files by staff and service users. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 14 16 17 The home is very pro-active in exploring opportunities for service users to access further education facilities. Service users access the local community and partake in a variety of leisure, recreational and social activities. However, the staffing levels should be reviewed for weekends and evenings to ensure that service users are given more opportunities. The home encourages family and friends to visit the home as much as possible. The home has a planned menu with choices offered. The home should consider reviewing the menu to further promote health living. EVIDENCE: On the day of the inspection two service users had been supported in visiting a local college to explore the possibility of accessing courses. The Inspector spoke to the service users when they returned and one service user confirmed that they enjoyed the visit. The Inspector was advised that four of the service users access college. All service users attend the Bill Cooke Centre that is adjacent to the home. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 13 Service users and staff that the inspector spoke to confirmed that they access a variety of leisure activities and local facilities, including visits to local shops, restaurants, art classes, hydrotherapy and drama. At the time of the inspection two service users were being supported to go to a local pub for lunch. A local taxi company was being used to take everyone to the pub a few miles away. The home has plans for service user holidays. A group of two service users and three staff are due to go to Disneyland, Paris in the very near future. Staff that the inspector spoke to commented that they would like to offer service users the opportunity to access more leisure and social activities. At present there are usually three staff on duty (minimum staffing levels) of an evening and at weekends, therefore it is not possible to support service users in accessing further activities at these times. This will be addressed in Standard 33. The home encourages contact with service user’s family and friends. The Inspector met with a parent of one service user. The parent commented that they are always made to feel very welcome at the home, that they are also kept informed, communication from the service is very good, they are involved in care planning and that they are very happy with the contact from the home. The home is located in a small cul-de-sac on a housing estate and is in close proximately of other properties. The manager stated that there are good relationships with the neighbours. The home has a kitchen/dining area that is very domestic in style and conducive to a family type environment so that everyone can sit around the table for meals. It is a pleasant area where service users can actively or passively be involved in meal preparation according to their assessed need. The home has a planned menu that is based on known likes and dislikes of the service users. The Inspector viewed a copy of the menu for a two-week period with the Registered Manager. Following discussions it was agreed that the menu should be reviewed to look at ways of further promoting healthy eating. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 20 Service users receive support in the manner they prefer and ensure that service users have access to all appropriate health care professionals. Good records are maintained in relation to the administration of medicines. EVIDENCE: The care plans that the Inspector viewed indicated the manner in which service users preferred to receive their personal care. All service users have an allocated key worker. There was evidence that staff are proactive in involving multi-disciplinary healthcare professionals, including appointments with physiotherapists, GPs, Speech and language therapists in addition to consultant specialists. Records are kept of all visits. The home has a mobility officer who works with staff to ensure that current and developing mobility needs are addressed. Care staff assist service users with personal care in the privacy of en-suites or the communal bathroom. Appropriate equipment is in place to allow people to be as independent as possible and to be assisted in a dignified manner. Staff that the Inspector spoke to confirmed that service users are offered choices in the clothes that they wish to wear. The Inspector noted that all the service users that he met were dressed in stylish and well laundered clothes. Hairstyles were modern and some female service users were wearing make up. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 15 The home uses the boots Monitored Dosage System and one member of staff is responsible for the ordering of medication. MAR sheets were well maintained. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 The home has a detailed complaints procedure and there are policies and procedures in place to safeguard vulnerable service users. However, the home should ensure that the management of services users finances are made more robust. EVIDENCE: A record is kept of complaints that are received at the home. There have not been any complaints since the last inspection. The Inspector spoke to one relative and they confirmed that they would feel comfortable if they felt that they needed to raise a concern or to make a complaint. The home has a number of systems to safeguard vulnerable people. The staff that the inspector spoke too at the inspection was aware of the home’s Whistleblowing Policy. This policy has been reviewed and updated as requested at the last inspection. The home has policies and procedures in relation to the management of service user’s finances. The Inspector viewed the documentation of service user’s finances. Each service user has a bank account / building society account in their name. All monies are kept safe and secure. There are no cash point cards. The service user’s individual parents manage their finances. However, cheques are available at the home and can signed by designated staff members for the withdrawal of monies. Records are kept of all transactions. The Inspector recommends that wherever possible two staff signatures be obtained for all transactions, especially at the evening check of service user’s wallets and purses. It is also recommended that the Registered Manager obtain a copy of the bank or building statements from parents for file and those statements are kept when obtained. The Inspector viewed the Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 17 finance records of two service users. Following discussions with the Registered Manager it was also agreed that he would review the arrangements for service users finances when staff support them on an activity. Records were well maintained and user friendly and appeared to be accurate. Staff do not commence work at the home until a satisfactory enhanced CRB clearance has been obtained. The Inspector viewed records in relation to this. The home does not use Physical Intervention. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 26 27 28 29 30 The home is fully accessible and designed to meet the needs of the service users as stated in the home’s statement of purpose. Bedrooms reflect individual lifestyles and needs. Toilet and bathroom areas are designed to meet individual needs. The shared space is very well maintained and is fully accessible to all service users. The home has many specialised equipment to maximise independence. On the day of the inspection the home was very clean and tidy. EVIDENCE: Fiennes House is a purpose built facility to provide accommodation to seven people who have a visual impairment and additional disabilities. The home is very comfortable and is designed to encourage independence for people with a visual impairment, there are tactile references around the home to enable service users to move around easily. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 19 All areas of the home are wheelchair accessible, including accessible pathways around the exterior of the home. There are many aids and adaptations around the home. An impressive water feature was being built in the front garden area of the home at the time of the inspection. The house is well maintained and furnished to a good standard. The home has addressed the areas identified at the previous inspection that were in need of attention. The Registered Manager advised that all areas of the home will be redecorated in the next few weeks. All bedrooms are of single occupancy. They were nicely decorated and contained personal possessions including family photographs, pictures, ornaments, television, hi-fi and sensory furnishings. Some bedrooms do not contain as much personal possessions due to their individual needs. Some rooms have overhead tracking and other aids and adaptations following assessed needs. Five of the en-suites have toilet and shower facilities, the remaining two have a toilet and wash hand basin and have the sole use of the main assisted bathroom. The Inspector recommended that the Registered Manager review the size of the washbasin in one identified service user’s bedroom, as this will enable better access to the toilet facility in the en-suite. On the day of the inspection all areas of the home were clean and tidy but still retained a very homely atmosphere. The laundry room has two washing machines and one dryer; one washing machine has a sluicing facility. All cleaning agents are always kept in a locked cupboard in the laundry room. A cleaning schedule for the home is in evidence. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 33 34 35 36 The staffing establishment and deployment of staff for the home does not at times allow the team to provide social and leisure activities of an evening and at weekends. This should be reviewed. The home has a very robust recruitment process and provides staff with appropriate training. Staff receive regular support and supervision. EVIDENCE: The Registered Manager stated that there is three staff on duty from the hours of 7.00am to 3.00pm, plus the housekeeper who conducts cleaning and cooking duties. There is three staff on duty from 3.00pm till 10.00pm. There is one waking night person and one sleep-in person. A separate staffing team is employed at the Bill Cook Centre in relation to daytime activities. However, staffing calculations for Fiennes House includes these hours. The rota the Inspector viewed confirmed this. It is the Inspectors opinion, and following discussions with some members of staff that at times not enough staff are on duty of an evening and at weekends to provide service users with more leisure and social activities, as there are usually the minimum staffing levels of three care staff on duty. For example, this does not allow two staff to take two or more service users for a daytrip or out for lunch as one staff member cannot Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 21 be left at the home with five other service users. The Inspector acknowledges that the home has recently reviewed the staffing levels at the home using the Residential Forum. However, the registered manager should review the staffing levels for evenings and weekends. The home has a very robust recruitment process. The Inspector viewed the staffing files for recently appointed staff. All records contained the appropriate documentation as listed in Schedule 2 of the Care Homes Regulations. It was not clear at the time of the inspection if a gap in particular employment history had been discussed at interview. The Registered Manager did not interview this person but stated that he will clarify this with the Human Resources Department. The home keeps a record of all individual training. A copy of an audit of all staff training was made available to the Inspector. The audit identifies the training that has been provided and when mandatory training is required. The Registered Manager has identified that some staff are in need of moving and handling, first aid and food hygiene training and is addressing this. The Training Record includes the status of the home in relation to NVQ qualifications. Currently seven staff have completed NVQ3 qualification and one staff is undertaking this qualification. All other staff are either undertaking NVQ 2 or 3 Qualification and are at various stages in completing this. This demonstrates the home’s commitment on providing a qualified work force. The Inspector was able to view some records in relation to staff supervision. Staff confirmed that they receive regular supervision. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 38 39 41 42 The home appears well run. The management approach of the home is very positive. The home has effective quality assurance systems. The home records all accidents in the home and ensures records are well kept. The home promotes the health, safety and welfare of service users. However, the home must improve on staff training in relation to fire safety. EVIDENCE: The Registered Manager of the home has worked at the home since July 2002. His first role was as a Senior Support Worker and was promoted to Acting Manager then Manager in April 2005. He has an NVQ3, Promoting Independence and A1 NVQ Assessors Award and is undertaking NVQ 4 Care and the Registered Managers Award. He has also undertaken various training courses related to his role. The staff that the inspector spoke to at the time of Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 23 the inspection stated that the Registered Manager is very supportive, listens to staff’s views, “sets the standard”, shows direction and leadership, very fair and “has the service users interests at heart”. The Inspector viewed the minutes to recent service user and staff meetings. The service users minutes clearly demonstrated that the home consults and informs service users as much as possible. Staff views and opinions are sought and open discussion and involvement is clear in all appropriate aspects of the running of the home. A satisfaction survey in relation to service users views was conducted in May 2005. One of the volunteers in the home independently carried this out on the home’s behalf. The Inspector viewed the outcome of the survey. It was very positive. The home has an Annual Development Plan. The Inspector was supplied with the plan for 2005/2006. The views of families and other interested stakeholders are sought. The inspector viewed the service records of the hoists, aids and ceiling tracking. All had been recently serviced as required. All fire records were inspected. The home’s Fire Risk Assessment is dated 13.06.05. Weekly fire checks, monthly testing of the emergency lighting, tests on torches and fire drills are undertaken with records kept. The fire alarm system and the emergency lighting were serviced on 16.05.05. The fire equipment was serviced on 06.07.04. It was noted that from the staff training records that some staff have not received fire training for a number of years. The Registered Manager must ensure that all staff receive regular fire training. An Immediate Requirement was issued at the time of the inspection. The home records all accidents. The Registered Manager as part of the audit process signs all all accident forms. The Gas Safety Certificate is dated 18.04.05. The Electric Hardwiring Certificate is dated 16.10.00. Environmental Risk Assessments were reviewed in February 2005. The home has a policy in relation to COSHH and all cleaning materials are kept secure. Portable Appliance Testing was conducted in June/July 2004. The home is informing the Commission for Social Care and Inspection of any incidents relating to Regulation 37 of the Care Homes Regulations 2001. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 4 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 2 Standard No 31 32 33 34 35 36 Score x 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fiennes House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 2 x D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 25 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 YA42 Regulation 23 (4) (d) Requirement The Registered Manager must ensure that all staff receive regular fire safety training. Timescale for action An Immediate Requireme nt was issued at the time of the inspection. 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. Refer to Standard YA17 YA23 YA27 YA33 Good Practice Recommendations The Registered Manager should review the menus to further promote healthy eating. The Registered Manager should review the management of service users finances to ensure the homes recording and auditing systems are robust as possible. The Registered Manager should review the size of one washbasin in an identified en-suite facility. The Registered Manager should review the staffing levels for evenings and weekends. This would enable service usesr to access more social and leisure activities. Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 26 Commission for Social Care Inspection Riverside Chambers Castle Steet Tangier, Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fiennes House D53_D02 S38170 Fiennes House V226884 160605 Stage4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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