Care Home: Fern Villa

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What the care home does well The service has taken action to replace the broken laundry equipment, repair the broken kitchen equipment, has a lifting hoist in place, currently has sufficient staff on duty, has adjusted the heating and hot water, has a current portable appliance test certificate and now orders food stores on a standing order basis with a delivery company. What the care home could do better: The service could make sure people have a choice of menu at lunch time, the main meal of the day, and that they are consulted about options and suggestions before meals are planned, so they are able to make choices in this area of their lives. The service could make sure everyone is living in a room that is suitable for them, safe and free from malodour and on the ground floor if necessary for their safety because of their personal conditions, so people are safe from the risk of accidents. The service could make sure all rooms are free from malodours so people live in a pleasant environment. The service could make sure the two hazardous carpet thresholds are replaced or repaired to remove the risk of tripping so people are safe.The service could make sure all staff administering medications have completed an accredited medication administration training course and that they are competence assessed before they are appointed to give out medicines, so people receive their medication safely. The service could make sure there is a cleaner employed for a minimum of five hours a day every day so that the home is clean and tidy and care staff have time to care, so people live in a clean environment. The service could make sure information on work completed to meet the requirements of the Fire Prevention Officer as listed against the visit on 16/02/10 is sent to Humberside Fire & Rescue Service as confirmation. The service could also make sure an annual maintenance check on the fire safety system is carried out in accordance with regulations, so people are safe from the risk of harm from fire. The service could make sure there are window opening restrictors on all upper floor windows and/or window safety fall bars where windows are of low positioning, so people are safe from the risk of falling through windows or climbing out of them. The service could make sure there is a legionella test certificate on the hot water tank if after investigation it is determined the tank is of the type that stores water at temperatures and needs regular testing. Random inspection report Care homes for older people Name: Address: Fern Villa The Green Ellerker East Riding Of Yorks HU15 2DP two star good service 21/01/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Janet Lamb Date: 3 1 0 8 2 0 1 0 Information about the care home Name of care home: Address: Fern Villa The Green Ellerker East Riding Of Yorks HU15 2DP 01430422262 01482666013 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Lesley Joan Francis Ellis Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Jeremy William Southgate care home 23 Number of places (if applicable): Under 65 Over 65 0 23 dementia old age, not falling within any other category Conditions of registration: 23 0 The maximum number of service users who can be accommodated is: 23 The registered person may provide the following category of service only: Care Home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category, Code OP, maximum number of places 23 Dementia, Code DE, maximum number of places 23 Date of last inspection 2 1 0 1 2 0 0 9 Care Homes for Older People Page 2 of 13 Brief description of the care home Fern Villa is a care home registered for 23 people over 65 years of age, of whom some may have dementia. The home is situated in the quiet village of Ellerker which is close to the M62 motorway. It is a converted house with a modern extension, which overlooks fields at the back and the village green to the front. The first floor is served by a stair lift for less ambulant people. There are two lounges available and one dining room and bathroom facilites meet the requirements of the standards in respect of numbers. There is a small sheltered garden to the rear of the house with patio furniture, though in the summer months people like to sit on the village green. There is car parking for approximately five cars. The home is privately owned. Weekly fees range from £360.00 to £450.00 per person per week. Extra may be charged if a double room is occupied as a single. Information about the service is made available to people via the statement of purpose, service user guide and inspection report, upon request. Care Homes for Older People Page 3 of 13 What we found: Sections ONE and TWO are not applicable to this random inspection. SECTION THREE Daily Life and Social Activities. Standard 12 was briefly discussed and information from the manager reveals there are no set activities facilitated by staff, as the staff do not have sufficient time on shift to do so. People do decide for themselves whether or not they want to play such as dominoes or cards and sometimes they gather to chat about current events or their families etc. The manager also says she has arranged and paid for some visiting entertainers over the last few months. Other contact with people and activities includes the local vicar once a month for communion and Days Gone By videos on occasion, as well as personal visitors. Standard 13 was not assessed. Standards 14 and 15 were assessed briefly in relation to menus and choice of foods only. Evidence from the menus on view and from discussion with the manager and provider shows there are no meal choices, except for when a person says they do not wish to have what has been prepared. There should be a set choice of main meal offered before preparation, which people are made aware of and can decide from. Choice in this and other areas should be explored and met where possible. A recommendation is being made to ensure people have the choice of a main meal during the day, that they are consulted about and can decide upon the options that should be on offer, and are given choice before meals are prepared. SECTION FOUR Complaints and Protection. Standard 16 was not assessed. Standard 18 was assessed and evidence shows there is no current risk to peoples safety because the manager has returned to work, staffing levels have been increased on the day shift and a new cook has been recruited. However there is still no cleaner. See Staffing section. Also equipment has been replaced or repaired. See Environment section. Finally the management arrangements have been resolved temporarily. See Management and Administration section. SECTION FIVE Environment. Standard 19 A safeguarding adults investigation has been carried out recently by East Riding of Yorkshire Council (ERYC) in respect of one persons safety, and in response to findings about other areas of care within the home and in particular the environment, the provider was requested at a strategy meeting on 11/08/10 to agree a plan of action and to carry out certain requirements before the given deadline dates. As part of the monitoring of these requirements ERYC officers made visits to the home to determine if Care Homes for Older People Page 4 of 13 the action plan has been met or not. This random inspection is also a monitoring visit to determine if action has been taken as well as in response to further information having been received about the status of the management and staffing. During the random inspection the equipment in the laundry was checked and evidence shows there has been a replacement washing machine and tumble dryer purchased. The kitchen was checked and the dishwasher has been repaired. Hot water and heating was discussed with the manager and provider and these have both been attended to so that there is now hot water after lunch time and the heating can be on during the night. It is essential that the provider ensures there is hot water at any time it is required and heating to a comfortable level through the day and night. Evidence was also seen to show that the bath and lifting hoist have both been maintained on 22/03/10 by York Elevator Services Ltd. Evidence of a Humberside Fire and Rescue Service visit made on 16/02/10 was seen and areas where requirments and recommendations were made were discussed with the provider. We were informed all work has been carried out in full though there is no evidence available to show this, and the provider is requested to make sure a response has gone or will go off to the fire prevention officer. This is also mentioned in the section on Management and Administration. The loose carpet threshold which is a trip hazard as identified at the strategy meeting has not been attended to and there is a second one on the same hallway by the rear entrance. These both need urgent attention and an immediate requirement notice was left to ensure the work is carried out within 24 hours. This is also mentioned in the section on Management and Administration. Standard 26 An area identified as unsuitable for use is one of the bedrooms on the upper floor of the old house. The carpet is very badly stained and malodorous and the room is not fit for use in its present state. The person staying in this room should be given an alternative and downstairs room on a permanent basis for two reasons, especially for their safety due to their personal condition and also for their comfort. A requirement is made in this report to ensure this occurs. An immediate requirement notice was also left to eradicate the malodour in two rooms by 13/09/10. SECTION SIX Staffing. Standard 27 The manager had returned to work from sick leave on the day of the site visit, which was an event we had not expected. There were also three care staff on duty and a cook, but no cleaner as we were informed no cleaners have been employed yet. Staffing rosters were seen for a three week period and though there had been one staff doing double shifts, accummulating 70 hours last week because of needing to cover in an emergency, no others had done excessive hours. Rosters were complete in respect of cover apart from Thurs 02/09/10 where a third staff was still to be allocated. The staffing situation appeared to be under control and in line with the requirements set in the strategy meeting, except for the management situation, but the manager was back on duty, and so no issues were identified. The manager informed us she would be leaving for another job in 2 weeks time and that Care Homes for Older People Page 5 of 13 she would be informing the provider of this later in the day. We were therefore unable to discuss arrangements for the management of the home with the provider during the site visit, but they could and would be discussed at the next planned strategy meeting to be held on 08/09/10, a week away. An immediate requirement notice was left for the provider to employ a cleaner each day of the week for a minimum of five hours per day by 13/09/10. We were informed by the provider that the deputy, the cook and one carer, all related to the manager, had been laid off because of an insinuation by ERYC officers that it was not always a good idea to have several people from the same family working in one home. The providers action was not required by ERYC nor was it warranted. Standards 28 29 and 30 were not assessed, though standard 30 does have a requirement against it to ensure staff giving out medication are trained in an accredited medication administration training course. See details in section seven Management and Administration. SECTION SEVEN Management and Administration. Standard 31 The manager was back in post from her sickness absence and so the problem of having no one in charge of the home was alleviated. The manager informed us she was only staying another two weeks as she had obtained a new job with another care provider. She said she would be handing in her notice later that day. There is currently no deputy employed in the home. One new staff had been employed two weeks ago and is already covering as acting deputy, but we informed the provider this is not appropriate. The provider explained there had been a misunderstanding as she was not covering the deputy role. The provider informed us he had been in day to day charge of the home while the manager was off. We were also informed that the person mentioned has been and is giving out medication even though she has not completed medication administration training. The provider informed us she has NVQ 3, but the manager clarified this is in teaching not caring. It was requested she does not take on a senior or deputy role until she has the relevant training and experience to do so and that she certainly does not administer medications without medication administration training. A requirement is made in this report under section six Staffing to ensure all staff handling and administering medicines only do so once they have completed an accredited medication administration training course. Standards 33 and 35 were not assessed. Standard 38 was looked at in relation to safety of lifting equipment, fire safety system maintenance checks and safety from falls due to trip hazards. Upper floor window safety and storage of hot water were also looked at. The homes lifting equipment, a sling hoist, was proven to be available and satisfactorily maintained. Fire safety was not satisfactory as there was only evidence of the annual fire safety maintenance check having been carried out on 28/01/09. There has been no annual Care Homes for Older People Page 6 of 13 check carried out in Jan 2010 as could be expected. An immediate requirement notice was left for this to be done by 06/09/10. There is evidence that weekly fire tests on the alarm and lights etc. have been carried out and that fire safety drills have been completed every three months. These details are recorded in a fire record book. There has also been a portable appliance test carried out on small appliances on 19/02/10. There are two threshold trip hazards identified to doorways off the rear entrance hallway, which need immediate attention and an immediate requirement notice was left for these to be attended to within 24 hours, under section five Environment. Other areas of concern are the malodours in two bedrooms and the safety of one person in an upper floor room. Advice was given about malodours, relocating one person downstairs and replacing carpets with soft lino in rooms where incontinence issues are difficult to manage. An immediate requirement notice was left to ensure malodours are eradicated or alleviated by 13/09/10 under section five Environment. It was observed that many upper floor windows in the old house are without opening restrictors and that some are of a low position, posing risk of injury from climbing out of them or from falling into them and through the glass. Requirements are being made in this report to ensure window opening restrictors and/or safety bars are fitted to ensure people are safe from the risk of harm from climbing or falling out of upper floor windows. Finally the provider should check whether or not the hot water is stored in a tank and if so he should arrange for a legionella water sample test to be carried out. A requirement is being made in this report to ensure this is done. What the care home does well: What they could do better: The service could make sure people have a choice of menu at lunch time, the main meal of the day, and that they are consulted about options and suggestions before meals are planned, so they are able to make choices in this area of their lives. The service could make sure everyone is living in a room that is suitable for them, safe and free from malodour and on the ground floor if necessary for their safety because of their personal conditions, so people are safe from the risk of accidents. The service could make sure all rooms are free from malodours so people live in a pleasant environment. The service could make sure the two hazardous carpet thresholds are replaced or repaired to remove the risk of tripping so people are safe. Care Homes for Older People Page 7 of 13 The service could make sure all staff administering medications have completed an accredited medication administration training course and that they are competence assessed before they are appointed to give out medicines, so people receive their medication safely. The service could make sure there is a cleaner employed for a minimum of five hours a day every day so that the home is clean and tidy and care staff have time to care, so people live in a clean environment. The service could make sure information on work completed to meet the requirements of the Fire Prevention Officer as listed against the visit on 16/02/10 is sent to Humberside Fire & Rescue Service as confirmation. The service could also make sure an annual maintenance check on the fire safety system is carried out in accordance with regulations, so people are safe from the risk of harm from fire. The service could make sure there are window opening restrictors on all upper floor windows and/or window safety fall bars where windows are of low positioning, so people are safe from the risk of falling through windows or climbing out of them. The service could make sure there is a legionella test certificate on the hot water tank if after investigation it is determined the tank is of the type that stores water at temperatures and needs regular testing. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 8 of 13 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13(2) The registered provider must 30/09/2008 make sure there is a suitable and secure place to store the new medication trolleys so that people are confident their medicines are stored securely and are not available to unauthorised persons. 2 19 23(2)(b) and (c) The registered provider must 30/10/2008 replace the carpets on the landing and in room 7. This is so people are confident they live in a safe, comfortable and homely environment. 3 19 23 The registered provider must 31/12/2008 refit and secure the paving slabs in the garden to ensure they do not pose a health and safety trip/fall hazard to people using the garden and grounds, so people know they will be safe when accessing the garden. The registered provider must 30/12/2008 make sure the toilets and bathrooms are kept in a good state of repair and Page 9 of 13 4 21 23(2) and 16(2)(c) Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action decoration, and contain the equipment required - the upper floor bathroom requires redecoration and a new floor covering, many toilets in the home require new floor coverings. This is so people are confident their environment is safe, clean and comfortable. Care Homes for Older People Page 10 of 13 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 19 23 The provider must eradicate the severe malodour from two bedrooms in particular. So people live in a pleasant environment. 15/09/2010 2 19 13 The registered provider must 15/09/2010 make safe the trip hazard carpet thresholds in the rear entrance hall. So people are safe from the risk of falls. 3 27 18 The registered provider must 15/09/2010 make sure there are cleaners employed in the home on a daily basis for a minimum of 5 hours a day. So people live in a clean and comfortable environment. 4 38 23 The registered provider must 15/09/2010 make sure there is an annual check carried out on the fire safety system. So people are safe from the risk of harm from fire. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 The registered provider must 16/09/2010 Page 11 of 13 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action make sure information about work done to meet requirements of the FPO is sent to the FPO as confirmation. So people are confident they are living in a fire-safe and well maintained home. 2 19 12 The registered provider must 16/09/2010 make sure one person identified is given the choice to move to a ground floor room. So this person is safe and comfortable. 3 30 18 The registered provider must 15/10/2010 ensure all staff administering medication complete an accredited medication administration course and are competence assessed before doing so. So people are given and receive their medication safely. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 15 The registered provider should make sure people are consulted about menu choices, options and suggestions before menus are planned and food is prepared, so they have choice in this area of their lives. Care Homes for Older People Page 12 of 13 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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