Inspection on 13/08/07 for The Fearnes

This inspection was carried out on 13th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Fearnes 17/03/09

The Fearnes 25/07/06

The Fearnes 22/02/06

The Fearnes 06/10/05

The Fearnes 18/01/05

The Fearnes 01/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Fearnes (The) 26 Knyveton Road Bournemouth Dorset BH1 3QR Lead Inspector Martin Bayne Key Unannounced Inspection 13th August 2007 10:00 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 Fearnes (The) DS0000003905.V348304.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. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fearnes (The) Address 26 Knyveton Road Bournemouth Dorset BH1 3QR 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) 01202 296906 01202 310065 fearnes@care-south.co.uk www.care-south.co.uk Care South Mrs Christine Knox Care Home 40 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (40) Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 40 in the category OP including up to 30 in the category DE(E) and up to 10 in the category MD(E) Two named service users (as known to the CSCI) in the category LD may be accommodated. Two named service users (as known to the CSCI) in the category LD(E) may be accommodated. 25th July 2006 Date of last inspection Brief Description of the Service: The local County Council built The Fearnes as a residential care home over 20 years ago. It is now part of Care South (formerly known as The Dorset Trust). The home is located in a residential area of Bournemouth close to the central shopping area and the travel interchange. The Fearnes is registered to provide care and accommodation for 40 older people and this includes 30 residents with dementia. The home is divided into four separate houses - Oak Way, Beech Way, Willow Way and Lilac Way. The three houses with residents who experience dementia have magnetic keypads fitted to the entrance to minimise the risk of wandering. Each unit has 10 bedrooms, a lounge, and a dining room and kitchen area. Assisted bathing and shower facilities are available and separate toilets are located close to residents’ bedrooms. The accommodation is available over two levels - ground floor and lower ground floor. Accommodation is provided in single bedrooms with vanity unit style washbasins fitted for use in each room. The home is decorated in a homely way and is comfortably furnished. The Fearnes is gradually being extensively refurbished and developed, current improvements include upgrading the laundry, relocating the home’s hairdressing room and improving the assisted bathing facilities in some bathrooms. The spacious and inviting entrance hallway has additional seating and a piano and provides a useful central focus to the home. The home has a passenger lift to enable easy and level access to both floors. The home has front and rear gardens with raised flower borders, mature shrubs and garden seating. A driveway to the front of the home provides off road parking. Christine Knox is the registered manager and Mr Roger Fulcher is the registered individual (RI) on behalf of Care South. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the home that took place between 9:35 a.m. and 2:45 p.m. The aim of the inspection was to follow up on the one requirement made at the last key inspection in July 2006 and to evaluate the home against outcomes of the key National Minimum Standards for older people. Since the key inspection of last year, a new Registered Manager has been appointed, however at the time of inspection they were on annual leave and so the deputy manager assisted throughout the inspection. The inspection included discussions with the deputy manager about how outcomes for residents are achieved, discussions with three members of staff, discussions with residents, observation of the interactions between staff and residents, a tour of the premises and inspection of records that the home is required to maintain. The fees for the home range from £450 per week to £600 per week. Any additional charges are detailed within the terms and conditions of residence. What the service does well: What has improved since the last inspection? Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 6 Some area of the home have been redecorated and new furniture provided. The new laundry area is now operational. One bathroom has been refurbished and new assisted bath fitted. 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. Fearnes (The) DS0000003905.V348304.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 Fearnes (The) DS0000003905.V348304.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Through carrying out an assessment of need before an offer is made for a person to move to the home, the home ensures that it can meet the needs of people admitted to the home. EVIDENCE: Pre-inspection information was returned to the Commission by the Registered Manager that informed of the procedure for admitting new residents to the home. Prospective residents or their relatives are initially invited to view the home. Following this, should they still wish to move to the home, the Registered Manager or deputy visits the person referred in their home or Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 9 hospital to carry out a pre-admission assessment of their needs. If it is decided that the home can the meet the persons needs, a letter is sent to the person or their relatives offering a place at the home. As part of the inspection, a sample of three residents’ personal files was used to track the required paperwork that the home must maintain on behalf of the residents. It was found that for each person the assessment of need had been recorded on a form. The form covered all the areas of need that are detailed within the National Minimum Standards. Letters informing that needs could be met at the home were also found within files. In circumstances where people are funded through Social Services, the home obtains copies of the care management assessment and care plan. The home does not provide a service for intermediate care. Fearnes (The) DS0000003905.V348304.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 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health needs are met through care planning, although managers should monitor the reviewing care planning to ensure that they are kept up to date. Residents have medicines administered safely and their right to privacy and being treated with respect is maintained. EVIDENCE: The home has a system whereby residents’ personal files are separated into a working file and an archive file, the working file being held in the unit where the resident resides. This ensures that staff have easy access to the files where they need to record information on a daily basis. The personal files for the three residents tracked through the inspection were seen. At the front of the file was a sheet recording key information and a summary of the persons Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 11 needs. Should a person need to go into hospital this sheet will be sent with the person to the hospital. The files also contained a photograph of the person and sections for; monthly reviews the current care plan, risk assessments, a sheet according visits from chiropodists and dentists, a record of accidents and incidents, monitoring charts, daily recording sheets and medication administration records. Within each resident’s file there was a care plan to inform the staff on how to meet the person’s assessed needs. The residents’ files sampled were chosen from different units within the home. The care plans in general gave sufficient information for a new member of staff to meet that persons needs. Daily recording sheets were also found to be completed. Concerning one resident’s care it was recorded in the daily notes by some staff that they were making two hourly turns of the person at night, however this was not detailed in the care plan. In the file of another resident, the monthly review sheet informed of a programme of exercises for a resident, however this had not been updated into the care plan. The deputy manager informed that it was the responsibility of the care team managers to ensure that care plans are up to date. It was recommended that systems for monitoring care plans being reviewed to ensure that they are kept up to date and provide consistent instruction for the staff. Residents or their representatives are involved in developing care plans and this was evidenced with one resident signing their care plan. The other two residents were being cared for in the dementia units and they did not have the mental capacity to be involved in developing their plans. This was recorded by ticking a box to this effect on their care plan. The homely uses a comprehensive risk assessment form assessing a range of risks. Each resident also has a separate moving and handling assessment form that is completed. Information from the risk assessments are then incorporated into the care plans. Within the care planning and risk assessments there was evidence that health needs were being met, with appointments being made with GPs when residents were not well and also regular visits being made from chiropodists, dentists and appointments with opticians. One of the residents spoken with who was able to give an account of what life was like in the home confirmed that health needs were met. From speaking with this resident and from observing the interactions between staff and residents and from speaking with relatives there was evidence that residents are treated respectfully and that the right to privacy is upheld. Time was spent with one of the senior members of staff discussing how medication is managed within the home. All of the residents currently accommodated in the home have their medication administered by the staff. The home has full policies and procedures for the safe administration of medication. Medication is managed separately on the two floors of the home, with a medication trolley on the upper floor and a cabinet on the lower floor. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 12 The keys for the trolley and the cabinet are held by the senior member of staff working in each area and there is therefore accountability each day for medication kept in the home. The home has appropriate facilities were storing controlled drugs should these be prescribed to a resident and there is a controlled drugs register to record administration of these medicines. The medication administration records were seen for residents on the upper floor. The file contained a sheet with sample signatures of the staff who have received training in safe administration of medication and it is these staff who administer medicines to residents. At the front of each recording sheet was a photograph of the resident and a record of how they prefer to take their medicines and a list of any known allergies. Medication administration records were being completed correctly with no gaps in the record and where hand entries were being made, two signatures were seen when one person had completed the record and a second person had checked its accuracy. The home uses a unit dosage system and medicines are delivered to the home by the pharmacist. The home has a fully auditable system recording all medication that enters the home, medication that is administered and how any surplus medication is disposed of. Three residents at the home had insulin-controlled diabetes with two of the residents having their insulin administered by subcutaneous injection by the staff. The staff who administer this medication have been trained and deemed competent by the district nurses to carry out this procedure. The district nurses set the insulin levels for the staff to administer and full records are kept of this. The home has a small fridge for storing medication that requires refrigeration and the daily maximum and minimum temperatures of the fridge are recorded. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from their spiritual, leisure and recreational needs being met and through being able to maintain contact with friends and family. They also are provided with a varied and balanced diet. EVIDENCE: The home employs an activities coordinator and records were seen of both group and individual activities carried out with residents. The residents spoken with who were able to give an account of life at the home informed that there were sufficient activities to keep them occupied. The staff spoken with were well acquainted with the life histories of residents, their interests and needs. Relatives spoken with informed that the staff were very supportive and caring towards the residents. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 14 Spiritual needs of residents are assessed when they move into the home. One resident had been a priest and the home had arranged for his superiors to visit the home for confession and to give Holy Communion. A Church of England service is also held each month in the home. Relatives spoken with informed they could visit the home at any time and stay for as long a period as they wished. They said that they were always made very welcome and that staff and managers will always accessible should they wish to speak to them. Relatives also informed that there were three monthly residents’ and relatives’ meetings held when they could raise and discuss any issues. The residents who had mental capacity informed that the food was of a good standard. They said there was a range of breakfast foods available and they could choose what they had for breakfast. At breakfast time residents are asked which of the three menu choices they would like their midday meal. The residents said that there was plenty to eat and the chef was very accommodating should they wish to have something different. One resident track to the inspection had been placed on food monitoring to ensure that their nutritional needs were being met. Another resident required a gluten free diet and there was evidence that this was being provided for. Build-up drinks were being provided for another resident who had nutritional needs. Care plans recorded were residents required assistance with eating. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well-publicised complaints procedure and through the staff being trained in adult protection. EVIDENCE: Since the last inspection there have been no concerns or complaints brought to the attention of the Commission. The pre-inspection information recorded that one complaint had been made to the management of the home. The complaints log was seen and there were full details of the complaint recorded and how this had been investigated. There was also evidence that an action plan had been put in place to address the problem raised. Complaints were therefore being taken seriously and acted upon. The complaints procedure is displayed in the front reception area of the home and is also detailed within the Statement of Purpose and the Terms and Conditions of Residence. Residents and their relatives are therefore well informed of how to complain. All of the staff receive training in adult protection as part of their induction when they start working in the home. More in-depth training is offered to senior staff from outside trainer. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 16 As reported at the last inspection, the home has copies of all the relevant policies and procedures relating to adult protection. Fearnes (The) DS0000003905.V348304.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a clean, well-maintained environment, however uncovered radiators in some areas of the building pose some risk to residents. EVIDENCE: The home is set in well maintained grounds, with car parking at the front of the home and a large enclosed garden at the rear to which all the residents have access. The grounds were well maintained. The home has a spacious front entrance that leads to the four units, each of which accommodates up to 10 residents. Each unit has its own communal area of lounge, dining area and Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 18 bathrooms. The units cater for residents with differing needs. One unit is for residents who have mental capacity but have needs relating to frailty of old age. The other three units are for people who suffer from dementia, with one of the units catering for people with more challenging needs. The three units that cater for people with dementia each have a locked door policy in order to protect residents from wondering from the home and getting lost. This information is documented within the Statement of Purpose. At the last inspection a requirement was made that where risk assessments concerning radiators indicated a risk, these radiators must be covered. The pre-inspection information returned to the commission did not inform how this requirement had been met. At this inspection a tour of the premises was made and it was noted that no new covers had been fitted to radiators. In some residents’ bedrooms a chest of drawers or other furniture was placed in front of radiators to protect residents fro hot surfaces. However there were some radiators that were exposed with chairs placed nearby. The view of the Inspector was these radiators could pose a potential risk to residents in view of their mental and physical frailty. This was discussed with the deputy manager and the home must take action to cover these radiators to protect residents. As reported at the last inspection the hot water outlets of the baths have thermostatic mixer valves fitted to protect residents from scalding water. It was evident that residents are able to bring furniture and possessions to personalise their rooms. Records were seen of furniture and valuables brought into the home. Since the last inspection the new laundry area has been completed and is equipped with a sluice, washing machines and dryers. The home has procedures and policies for infection control and alcohol gel dispensers were evident around the home. Staff are provided with protective clothing such as gloves and aprons. The home was found to be clean with no adverse odours. Fearnes (The) DS0000003905.V348304.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 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are met by a committed, well trained staff team who are recruited in line with best practice, however the home should ensure that agency staff have also been recruited to these standards. EVIDENCE: The home maintains the same levels of staffing as reported at the last inspection. Between 7:15 a.m. and 10 p.m. there is a minimum of seven staff on duty. In addition to the care staff, during weekdays the manager and deputy work office hours. The home also employs ancillary staff of a laundry assistant who works from 9:30 to 3:30, 7 days a week; domestic staff employed for 80 hours a week, a chef, assistant chef and kitchen assistance for 69 hours a week, an activities coordinator for 20 hours per week an administrator for 20 hours a week. The residents spoken with whom are able to give an account of life at the home said that their needs were met by the staff and if they had reason to press their call bell, staff responded promptly. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 20 The staff are delegated to work within each unit but can be called to assist in other areas should there be an emergency. During the inspection one resident slipped from their wheelchair to the floor. Staff were seen to act appropriately with other staff being summoned and the resident was safely hoisted from the floor back to the chair. Throughout this procedure the staff reassured the resident and informed them of what they were doing. At the last inspection the home had a ratio of 33 of staff training to NVQ level 2. At this inspection it was found that the home has now achieved a level of 50 of the staff trained to NVQ level 2. Staff recruitment files for three people employed since the last key inspection in July 2006 were seen. It was found that all the checks and records required by Schedule 2 to the Regulations had been complied with including; proof of identity, photograph, a health declaration, two written references, a completed application form, a check against the register of adults deemed unsuitable to work with vulnerable adults, a criminal record bureau check and a signed rehabilitation of offenders declaration. It was also found that staff did not start work in the home until they had been cleared against the register of people deemed unsuitable to work with vulnerable adults. It was recommended that the staff application form be amended to request information required by the regulations; such as, a reference from person’s last place of employment where they worked with children or vulnerable adults for a period of three months or more, a full employment history with gaps in this history accounted for. The pre-inspection information recorded that the home on occasion uses agency staff. The deputy manager was not aware that the agency should supply a letter for each new agency worker to inform that they had been subject to all the recruitment checks of Schedule 2 of the Regulations. It is strongly recommended that the home should receive such a letter before they take on a worker from the agency. All new staff complete a five day induction training programme developed by the organisation that is compliant with standards set by Skills for Care. Training records was seen within the files for the staff whose recruitment records were seen. All staff receive mandatory training in areas such as; health and safety, fire safety, moving and handling, infection control, basic food hygiene, first aid and adult protection. All of the staff receive some training on how to care for people dementia and senior staff can also develop their expertise on further courses on dementia provided by an external trainer. Fearnes (The) DS0000003905.V348304.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 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run with interests of resident’s paramount. EVIDENCE: As reported in the summary, a new Registered Manager and also new deputy have been appointed since the last key inspection in July 2006. Both manager and deputy have an NVQ level 4 qualification and also the Registered Managers Award. Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 22 The home carries out an annual survey that involves residents and relatives. From the accounts of what life was like in the home given by residents who have mental capacity and relatives spoken with, there was evidence that the home was run in the interests of the residents. Residents informed that routines were flexible and that they were able to get up and go to bed when they choose. They also said that they were supported to maintain their interests and hobbies. The home safe keeps small amounts of money for some residents. The records were seen for the three residents tracked through the inspection and the money held on their behalf was counted. Good records were being kept with a record money deposited, taken out and balance of money held. The amounts of money tallied with the balances. Receipts are kept to any items on purchases made. The pre-inspection information supplied by the Registered Manager informed tests, records and servicing of equipment in the home, including the fast safety system are carried out to the required timescales. Fearnes (The) DS0000003905.V348304.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fearnes (The) DS0000003905.V348304.R01.S.doc Version 5.2 Page 24 Yes 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 OP19 Regulation 13(4)(c) Requirement The home must review the risk assessments regarding uncovered radiator and covers those that pose a risk to residents. Timescale for action 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the home monitor reviews of care plans to ensure that they are up to date and provide consistent instructions for the staff on how to meet the needs of residents. It is strongly recommended that when agency staff are used, the home ensures that all recruitment checks required by legislation are met by obtaining a letter to confirm this from the agency. It is recommended that the staff application form is changed to request information in line with information required by Regulation. DS0000003905.V348304.R01.S.doc Version 5.2 Page 25 2 OP29 3. OP29 Fearnes (The) Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Fearnes (The) DS0000003905.V348304.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. 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!