Care Home: Fernbank

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What the care home does well Fernbank obtains a professional assessment of need and undertake their own assessment prior to people being admitted into the home. Good social histories provide staff with knowledge of people`s preferred lifestyles. Effective communication systems and regular community meetings mean that people have a say in their daily lives and running of the home. Many people were involved in the home, for example, cooking and helping with light domestic chores.One relative questionnaire said "Fernbank has provided me with a copy of their code of practice and I also receive copies of regular reviews." Another said "The care and treatment my relative receives exceeds my expectations." People were complimentary about the good quality of food, which the inspector also experienced on the day. The home`s AQAA stated that they have introduced more opportunities for healthy eating by offering low fat alternative food and fresh fruit being offered alongside morning snacks. They have continued this theme by operating a cessation-smoking group with the help of their local GP practice. Comments from people in the home included "I feel that the care home does everything well" and "It is a lovely place for me and I am happy at Fernbank." What has improved since the last inspection? Since the last inspection the manager has improved the recruitment and selection procedures in line with a requirement made on the previous inspection. Certain areas of the home have undergone redecoration, especially in people`s bedrooms. The AQAA states that a health care workers` book has been developed where everyday staff record the physical and medical care needs of people in the home. What the care home could do better: A review of recording systems needs to take place to ensure duplication does not happen and consistency is maintained. This will help ensure staff do not become confused as to what care needs to be delivered. In-house training must be assessed to ensure staff are provided with up to date information. One aspect of medication administration needs to be discussed with health professionals to ensure that staff remain up to date with information.Some aspects of the environment needed to be addressed. The manager compiles a refurbishment plan and the inclusion of a replacement carpet for the large lounge, together with a television which enables all people to see the screen should be included in this to ensure the good standards in the home are maintained. We noted that, on occasions, the manager failed to inform us of incidents in the home under Regulation 37 of the Care Standards Act 2000. We must be informed of any adverse events, which may affect the wellbeing of people in the home. CARE HOMES FOR OLDER PEOPLE Fernbank 93 Queens Road Oldham Lancashire OL8 2BA Lead Inspector Sandra Buckley Unannounced Inspection 24th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fernbank DS0000005506.V351882.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. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernbank Address 93 Queens Road Oldham Lancashire OL8 2BA 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) 0161 626 4079 F/P 0161 626 4079 Mr Mark Brakspear Mrs Margaret Lorraine Brakspear Mrs Lynda Bennett Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (13) Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user up to 13 OP, up to 10 MD and up to 10 MD(E). Date of last inspection 10th October 2006 Brief Description of the Service: Fernbank is a detached, Victorian property, registered to provide care for up to 23 people suffering from mental health problems and for people with disabilities resulting from old age. Their aim is to provide community based living with integration into the wider community, where possible, for those service users with mental health problems. Facilities include seven single bedrooms and eight double bedrooms. Several bedrooms have en-suite toilets. There are four lounges, one of which is the home’s smoking area, and one dining room. There was a well-maintained garden to the front of the building and a smaller, secluded, patio garden area to the rear. The home is a privately run business owned by Mr and Mrs Brakspear. At the time of this visit Fernbank’s fees ranged from £313.88 - £425.00. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which included an unannounced site visit, was made to the home on 24th October 2007. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care Inspection (CSCI) about the service provided at the home since the last inspection. The manager was not informed before the visit that we were coming. During the site visit information was taken from various sources that included observing care practices and talking to people in the home. The manager, relatives and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned from residents and their relatives are also included in this report. All the requirements made at the last inspection had been addressed. Before the inspection, we asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home sees the service they provide the same way that we see the service. We felt this form was completed honestly and that time and effort had been given to completing it in detail, with the manager and provider having a clear understanding of what improvements could be made and what they do well. We have used some of the information provided to us in this report. What the service does well: Fernbank obtains a professional assessment of need and undertake their own assessment prior to people being admitted into the home. Good social histories provide staff with knowledge of people’s preferred lifestyles. Effective communication systems and regular community meetings mean that people have a say in their daily lives and running of the home. Many people were involved in the home, for example, cooking and helping with light domestic chores. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 6 One relative questionnaire said “Fernbank has provided me with a copy of their code of practice and I also receive copies of regular reviews.” Another said “The care and treatment my relative receives exceeds my expectations.” People were complimentary about the good quality of food, which the inspector also experienced on the day. The home’s AQAA stated that they have introduced more opportunities for healthy eating by offering low fat alternative food and fresh fruit being offered alongside morning snacks. They have continued this theme by operating a cessation-smoking group with the help of their local GP practice. Comments from people in the home included “I feel that the care home does everything well” and “It is a lovely place for me and I am happy at Fernbank.” What has improved since the last inspection? What they could do better: A review of recording systems needs to take place to ensure duplication does not happen and consistency is maintained. This will help ensure staff do not become confused as to what care needs to be delivered. In-house training must be assessed to ensure staff are provided with up to date information. One aspect of medication administration needs to be discussed with health professionals to ensure that staff remain up to date with information. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 7 Some aspects of the environment needed to be addressed. The manager compiles a refurbishment plan and the inclusion of a replacement carpet for the large lounge, together with a television which enables all people to see the screen should be included in this to ensure the good standards in the home are maintained. We noted that, on occasions, the manager failed to inform us of incidents in the home under Regulation 37 of the Care Standards Act 2000. We must be informed of any adverse events, which may affect the wellbeing of people in the home. 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. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 8 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 Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 9 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. People’s needs are appropriately assessed and they are able to visit before a decision is made that the home is appropriate for them. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three people’s files were looked at in depth, from their admission through to care planning and care delivery. Files contained health care professional assessments and an assessment undertaken by the manager to ensure people’s needs can be met before entering the home. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 10 People are given information prior to entering the home and a copy of this is held within their rooms. One person said, ‘I had daily visits to the home before I moved in.’ Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 & 10 Quality in this outcome area is good. Systems and procedures in place support residents in having their personal and health care needs met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Files examined included care planning, risk assessments and good social histories, which were linked to people’s assessment of needs. Detailed instructions to staff on care delivery were in place. In some instances, all the details on professional assessments had not been transferred to care planning, for example, obsessive compulsive behaviour. The manager said this was because the home’s assessment had not identified any continuing problems with behaviour which were linked to past history. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 12 However, an audit trail of this decision needs to be documented clearly to ensure people’s needs are met. Recording systems were not streamlined and much of the paperwork needed to be archived. Some things were duplicated which led to inconsistencies in recording, an example of this being one health care record that stated a person’s legs need to be raised to alleviate swelling. This was recorded in daily notes but not on care planning. Outcomes for people remained positive due to good communication systems and staff diligence. At interview, staff demonstrated good knowledge of people’s needs and said they were encouraged to read care plans when time permitted. Health care visits were recorded and there was evidence that the manager had initiated visits to consultants and specialist workers. The home had worked closely with health professionals to establish a smoking cessation group, which some people had managed to achieve. People’s preferred bath times were also recorded. The manager works closely with community psychiatric nurses and other mental health professionals. People in the home were well presented, clean and tidy. Thought had been given to people’s self image, for example, nails polished and jewellery. Questionnaires returned from relatives show that all felt staff had appropriate skills and that people received sufficient care to meet their needs. One relative commented that: ‘Fernbank has provided me with a copy of their code of practice and I also receive copies of regular reviews.’ Another said, ‘The care and attention my relative receives from staff and management at Fernbank exceeds my expectations.’ Also, ‘I feel my mother is well cared for, the staff treat her with respect and kindness and have regard for her.’ Staff confirmed at interview they had appropriate equipment to meet people’s needs and promote independence. Staff training and induction is mostly undertaken in-house by the provider and manager. This practice must be kept under review in order to prevent training becoming insular and keep up to date with new developments in care provision. One person said, ‘I feel the care home does everything very well,’ and ‘They always call a doctor if I need one.’ Also, ‘I have an alarm bell for if I need any help in the night.’ Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 13 Medication procedures were, in the main, safely documented and administered, the exception being one person who occasionally requires specialist treatment. This practice is carried out by a member of staff. The manager said training had been provided about three years ago. However, no evidence could be found to support this. This practice must cease until appropriate specialist training is received with health professionals. The manager said she would undertake discussions with professionals involved. Photographs of people need to be on medication sheets to enable new staff to recognise individuals. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 & 15 Quality in this outcome area is excellent. An appropriate range of activities and social stimulation is provided. Choices are offered in people’s daily life and meals are well balanced. Communication systems provide people with a voice in the home, promoting their sense of fulfilment. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: People in the home said routines are flexible and they have choices in their daily lives. One person’s questionnaire said, ‘It is a lovely place for me and I am happy at Fernbank.’ Good social histories were on file providing staff with information of people’s previous lifestyle in order to understand their behaviour and personal needs. An example of this being one person wishing to have an alarm clock set for 9:00am, which the night staff set for them. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 15 Communication is high on the agenda at Fernbank, with Monday community meetings being held. The last one was on 22nd October 2007. The agenda consisted of discussions on a forthcoming trip to Coliseum with a meal beforehand. Minutes also stated that people were reminded if they had any concerns they could discuss these in private with the manager or provider. One person said they enjoyed a recent trip to Blackpool and another said ‘Staff treat me very nice and I like to be with staff.’ Trips to the local pub were also mentioned a number of times, with people saying they really enjoyed these together with outings to the local park. People are encouraged to join in the daily tasks of the home, i.e., setting tables and washing pots. One person who enjoyed cooking had cooked the alternative choice of main meal, which was chicken curry. A number of people chose this option, which they really enjoyed. One person said, ‘the cook comes around every day and asks us what we want for lunch.’ The inspector dined with people in the home and was served in a congenial setting with a choice of roast beef or chicken curry. The meal itself was presented in an appetising manner and was extremely tasty. All the people spoken to said the food is always tasty and to a good standard. Good interventions were observed with people and staff and several friendships had developed in the home. There is a small kitchenette area where people can prepare drinks and snacks outside mealtimes. The provider had stated in the AQAA that visitors are allowed to visit at any time if the people wished it. Lay people from local churches also visit. The document also identified improvements that had been made, for example, increased selection of activities in the afternoon and promotion of healthy eating, offering low calorie alternatives and fruit alongside afternoon snacks of cake and biscuits. One relative questionnaire said ‘My relative’s quality of life has been enhanced since living at Fernbank.’ A number of people have chosen to have a TV in their room. One person said, ‘I like to go to my room and watch TV so I can watch what I want.’ In the main lounge the TV had a small screen, with some people in certain areas of the lounge finding it difficult to see. The manager said they had recognised this and it was due for replacement. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18 Quality in this outcome area is good. People and their relatives were confident that any complaints they may have would be dealt with appropriately. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home’s complaints procedure is in the service user guide and specifies how complaints may be made, timescales for action and who will deal with them. A record of complaints is maintained, the last one recorded in June related to a member of staff’s attitude. The manager had investigated this and the inspector was satisfied that this had been dealt with appropriately. One person said, ‘I would see the manager if I was upset about anything.’ All the relative questionnaires returned said they knew how to make a complaint. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 17 Protection of vulnerable adults training needs to be provided to all staff working in the home. Although staff demonstrated how abuse presents, and what to do in such circumstances, a recognised training course in the protection of vulnerable adults should be undertaken. Staff who had qualified to NVQ level 2 had received instructions on the protection of vulnerable adults. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 18 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): Standards 19 & 26 Quality in this outcome area is good. People live in a pleasant, safe and hygienic environment. The continuation of the home’s refurbishment plan will ensure comfort standards are maintained for people in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Fernbank provides accommodation over three floors. A tour of the premises noted that the top floor provides two shared rooms, each with their own bathrooms. All the shared rooms in the home are provided with privacy screens. Rooms were clean, tidy and free from odour. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 19 The provider and manager stated in the AQAA that in the previous year, patio doors had been fitted from a smoking lounge into the garden, which also provided additional ventilation. Other communal areas comprise of a small lounge on the second floor that can be used for privacy for visitors or a quiet space. Downstairs there is also a dining room and two other lounges. redecoration and refurbishment had taken place. Adaptations and independence. equipment had been provided to promote Some people’s The provider’s AQAA stated their plans for the next 12 months were to create two en-suite bathrooms and a shower room on the ground floor. Observations made throughout the day found that all the chairs in the home had seats covered in sheepskin, which provided an institutional feel. Most people in the home were of a younger age group and mobile, therefore did not require these for pressure care. Another observation was that the main front lounge carpet was stained and worn with lines of the floorboards showing through. It is recommended that this issue also be included in the home’s refurbishment plan in order to provide a more congenial environment for people to sit in. The manager said this had been recognised and discussed with the provider. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30 Quality in this outcome area is good. The number and skills mix of staff promoted the independence and well being of people in the home. Recruitment and vetting procedures were robust offering protection to people in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of the duty rota on the week of inspection found that staff were employed in sufficient numbers to meet people’s needs. During the day, three staff, manager and provider are on duty in the home. Three staff continue through to the evening shift with two staff covering night duty. In addition to this, cooks and ancillary staff are employed. The make-up of the staff team reflected the age and culture of the client group. Half the staff team had qualified to NVQ level 2 and all staff had a training and development file. Staff training and induction is given a high profile, with much of the training and induction provided by the manager and provider. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 21 There is a risk that training may become insular under these circumstances. The manager said that they had recently been talking to the training section of Oldham Social Services in order to access additional training. This is particularly necessary for training in the protection of vulnerable adults. Staff at interview had a good knowledge of people’s needs, both physical and emotional. Staff felt they were kept well informed in handovers and staff meetings of any changes in care or developments in the home. Two recently recruited staff’s files were examined and were found to have appropriate checks and references in place. One person said, ‘Staff treat me very nice and I like to be with staff.’ Another said, ‘Staff and the owners are very friendly.’ Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 37 & 38 Quality in this outcome area is good. Good communication and audit systems provide an open and inclusive environment for people in the home. Protection for people in the home is maintained through the implementation of the home’s health and safety policies. This judgement has been made using available evidence, including a visit to this service. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is qualified to NVQ level 4 and has completed the registered manager’s award. They also have many years’ experience in the care of the elderly and people with mental health problems. They have continued their professional development through completing short courses in infection control, nutritional screening and food hygiene. Good communication systems are in place to ensure both staff and the people who live there are kept informed of any new developments. An example of this is the Monday morning meetings, when the week’s activities are discussed and suggestions are sought for future events. Observations made on the day of inspection showed that people were actively involved in cooking and some daily chores to the level of their capability, promoting ownership and a sense of belonging. There was evidence that the management team are proactive in promoting equality and diversity in recognising the needs of people from different cultures in the preparation and choice in food. Staff meetings are held on a regular basis with the daily handovers at change of shift providing up to date information on people’s needs. At interview, staff said they received regular supervision to discuss their professional development. A quality assurance system seeking the views of professionals, relatives and people in the home is in place, with results being published in the service user guide. In the AQAA completed by the home, the provider and manager had recognised that the quality assurance system could be enhanced by the implementation of staff questionnaires. A selection of records relating to money held by Fernbank on behalf people in the home was looked at. The records were appropriately maintained with receipts for items purchased being retained. Although outcomes for people in the home remained positive, the recording systems would benefit from a more streamlined approach to prevent duplication and the archiving of old irrelevant information. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 24 During the inspection no obvious risks to the health and safety of people in the home were observed. A selection of records relating to the routine maintenance of equipment in the home was examined and found to be well maintained. Fire drills and the checking of equipment were up to date with staff confirming their involvement. It was noted that two incidents had occurred in the home affecting the wellbeing of individuals, which the manager had failed to inform the CSCI under Regulation 37 of the Care Homes Regulations 2001. The manager was advised that the CSCI must be kept informed of any such events. The outcomes for individuals remained positive and the inspector was satisfied that the home had undertaken appropriate in-house procedures on this occasion. Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 25 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 x 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 3 X 2 3 Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13 Requirement Ensure health professionals undertake special treatments or that staff in the home have undertaken appropriate training to ensure people’s health care needs are met. Timescale for action 30/11/07 Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 27 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 All the identified needs of people should be transferred from their professional assessments into care planning. An audit trail of any changes made should be documented, to ensure the protection of people in the home. Photographs of people receiving medication should be placed on medical records to ensure appropriate identification. The provision of all staff having received training in the protection of vulnerable adults will ensure people’s safety in the home. Keep under review the provision of in-house training and induction to ensure training does not become insular and people are kept up to date of new developments. Include in the home’s refurbishment plan a replacement carpet for the main lounge area and a television which enables all people to view. Review recording systems to ensure consistency in recording, archive information and reduce duplication. 2 3 OP9 OP18 4 5 OP26 OP37 Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Area Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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 Fernbank DS0000005506.V351882.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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