Care Home: Fernleigh House

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What the care home does well This home is keen to provide and develop good quality support for people using the service. The home was being well managed by a capable person. There was a good way of finding out about peoples` abilities, needs, likes and dislikes before they moved into the home. People living at Fernleigh House were being involved with different activities and were getting out into the community. People living at Fernleigh House were being given a lot of support to stay in touch with families and friends. People were being involved as much as they were able, in making decisions about how they spend their time.Help with personal needs was being given with care and people were being treated with respect. The staff team were enthusiastic and keen to provide a good service; they worked very well with the people living in the home. To make sure they knew what to do, staff were being given regular training. The home provided a comfortable, attractive and clean living environment for people living in Fernleigh House, with lots of outside space for them to enjoy. What has improved since the last inspection? This was the first inspection following registration of the service. What the care home could do better: Individual Plans for people using the service needed some further details; to make sure staff know exactly what to do for each person and how to treat them. Improvements were needed with some medication matters; to make sure people are properly and safely supported. To make sure managers and staff do the right thing to make sure people are properly protected, some further instructions for dealing with abuse matters were needed. CARE HOME ADULTS 18-65 Fernleigh House 1 Fernleigh Leyland Lancashire P26 7AW Lead Inspector Mr Jeff Pearson Unannounced Inspection 11th June 2008 09:00 Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernleigh House Address 1 Fernleigh Leyland Lancashire P26 7AW 01772 468019 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) Progress Adult Services Ltd Mr Andrew Law Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of people who can be accommodated is: 6 Date of last inspection This was the first inspection Brief Description of the Service: Fernleigh is a care home providing accommodation personal care and support for 6 adults with severe learning disabilities, complex behavioural needs and communication difficulties. Fernleigh house is a detached modern home decorated and furnished in a contemporary style. There are two lounges a dining room, and an arts and crafts room. All the bedrooms are single; four have en-suite facilities. There are sufficient bathing facilities and toilets. There is a large enclosed garden to the rear of the home, providing outside activity equipment and seating. The service philosophy is based upon providing people with a structured and fulfilled life, which builds upon each persons abilities, offering activities and opportunities for skill development with the aim of enabling each individual to be as independent as possible. Staff are available to provide support and personal care, in response to individual needs and abilities. The home had a Statement of Purpose and Service User Guide providing information about the support, care and services available. This information should help people make an informed choice about moving into Fernleigh House. At the time of the inspection visit the range of fees was between £2,651 and £3,228 per week. Toiletries, clothing and personal items were not included in the fees. There were additional charges for holidays, with staff support being funded by Progress Adult Services Ltd. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people using this service experience Good quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Fernleigh House on the 11th June 2008. The visit took 8 hours and was carried out by one inspector. The people using the service, their relatives and staff were invited to complete surveys, to tell the Commission what they think about the care service provide at Fernleigh House, some were received at the Commission. Prior to the site visit, the registered person was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of two people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spent time with the people using the service; spoke with the registered manager, staff and the head of service. As the younger adults had specific needs with communication, we did not fully engage with them in verbal discussion. Various documents, including policies, procedures and records were looked at. Some parts of the home and grounds were viewed. What the service does well: This home is keen to provide and develop good quality support for people using the service. The home was being well managed by a capable person. There was a good way of finding out about peoples’ abilities, needs, likes and dislikes before they moved into the home. People living at Fernleigh House were being involved with different activities and were getting out into the community. People living at Fernleigh House were being given a lot of support to stay in touch with families and friends. People were being involved as much as they were able, in making decisions about how they spend their time. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 6 Help with personal needs was being given with care and people were being treated with respect. The staff team were enthusiastic and keen to provide a good service; they worked very well with the people living in the home. To make sure they knew what to do, staff were being given regular training. The home provided a comfortable, attractive and clean living environment for people living in Fernleigh House, with lots of outside space for them to enjoy. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The admission process ensured peoples’ needs; abilities and aspirations were known and planned, for before they moved into the home. EVIDENCE: The homes’ brochure and service user guide were seen to be available; the guide had been produced in a format to make it as accessible as possible to the younger adults using the service, it included pictures and symbols which may be helpful for some people. The statement of purpose had been recently revised and updated, to reflect all the categories of people the home may accommodate. The registered manager said all the younger adults had individual contracts supplied by the appropriate Social Services directorates, it was not clear if the home had agreed or specified the terms and conditions of residence with each person, this matter therefore needed further attention. The manager explained the homes admission process, that more senior managers would undertake the initial assessment and he would also be Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 9 involved in the process. Careful consideration being given to the needs and abilities of the individual concerned, with equal attention being given to their compatibility with younger adults currently living at Fernleigh House. Assessment information was being obtained from appropriate sources, for example Social Services. This combined information was usually being kept on the younger adults file for staff access and reference. Records and discussion showed that good systems and practices were in place for managing both planned and emergency admissions. W here possible, people were being supported to move into the home gradually, carefully arranged in response to their particular needs and preferences. This could involve planned visits and working closely with other carers and families. Discussion took place about a recent emergency admission, which appeared to have been managed sensitively; action had been taken gather information and respond to identified needs, a detailed support plan had been drawn up in good time. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that plans were being made to develop assessment documentation to reflect a person centred approach, make it more positive by using information about the present and future rather than lots of information about the past. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care planning process helped ensure peoples’ individual needs, abilities and choices were known and effectively responded to. EVIDENCE: Care plans seen were very person centred and included much relevant information about peoples needs, abilities and goals, including, personal profiles, ‘Essential Lifestyle Plans’, support networks, support with religious needs and sensory programmes, also very specific plans in response to behavioural needs. Some of the plans included pictorial symbols to help make them more accessible to the younger adult. Systems were in place to regularly monitor peoples’ life and situation and reviews were being carried out on a regular basis. Any changes in support needs were being identified and brought of the attention of staff. Some ‘short term’ goals and the necessary responses, Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 11 were not always recorded to provide clear instructions for staff, this matter was discussed with the manager. People living at Fernleigh House were observed to be sensitively involved in many activities of daily living; for example, they were consulted about day to day matters such as meals, drinks, TV programmes, outings, how they spent their time and other matters which affected them. Promoting choices included giving people opportuities to and try and experience various activities, monitoring to see if they enjoyed them and ensuring their individual needs and wishes were then known and planned for. Any limitations on choices had been identified and agreed. Consideration had been given to individual behavioural needs, with positive interventions being devised to minimise self-harm and potential harm to others. This approach aimed to ensure safety risks are assessed, but balanced with effectively promoting independence, rights and choices. Strategies seen were person centred, with staff being guided to be aware of what the may do, the reasons why and the staff qualities required to respond. General risk assessments had been completed in relation to some health and safety matters, such as accessing the garden and using transport. The AQAA (Annual Quality Assurance Assessment) completed by the manager showed all staff were being encouraged to attend care plan meetings. Plans for improvement included further involvement of friends and families with care reviews and developing the care plan format to be more person centred. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service were being offered opportunities to develop their skills, engage in activities and use community resources. EVIDENCE: People moving into Fernleigh House were had been supported to continue with any preferred activity and were being encouraged to pursue new interests. For example, one person had a list of activities they wanted to do which had been devised as part of admission process. Records and discussion showed cultural backgrounds and religious needs were being considered and responded to accordingly. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 13 Systems were in place to ensure people are supported to have development opportunities and enjoyable activities each day, with individual schedules being devised to provide a structured, but flexible approach. People living at Fernleigh were seen to be kept occupied and supported by staff, to undertake various activities in response to their individual needs, limitations and ability. Daily diary notes and observations showed peoples involvement in activities and outings. The manager spoke of the various activities, both in and out of the home, including a trampoline in garden, swing, dance mat, activity room with craft items, computer, music systems, TVs and DVDs. Bus passes were being obtained and consideration was being given to accessing the local gym, cookery and art classes. One staff member explained that all the younger adults are supported to go out each day, this sometimes being on their terms, “to promote a good quality experience” People were seen to have much freedom of movement in the building; they could make use of their own rooms and other areas, there were some restrictions for health and safety reasons. Records showed people’s relationship needs were being considered; people were being supported to keep in touch with families and others as appropriate. Staff spoken with said, arrangements were being made to provide support for one person to have a day out with their family. Individual food likes and dislikes were known, specific diets for cultural, health and religious needs were being catered for. Mealtimes were flexible, depending on what was happening each day. Menus appeared varied; the manager said they could be changed to respond to peoples’ preferences and living patterns. Records were being kept of meals and foods taken by each person. Some pictures of food had been used to help people make choices. Fresh produce, including vegetables and fruit was seen to be available. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that finding relevant and appropriate community resources for people to attend, as an area for development. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Most health and personal care practices and procedures were effective in ensuring people’s needs are properly and safely met. EVIDENCE: The care planning process included much emphasis upon providing person centred care; therefore peoples’ preferences on how support is provided was being tailored to best meet their needs. The home operates a ‘key worker’ system which involves staff being linked with a particular resident to provide continuity and a more personal service. The home employs male and female staff; the manager said that gender issues were given priority when providing personal care. All interactions observed between the younger adults and staff appeared very sensitive; staff were respectful and genuine in their approaches when providing support and guidance. Staff had received training in delivering person centred care, promoting dignity and privacy. One staff member spoken with explained Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 15 that privacy and dignity was paramount at the home, saying “We leave their rooms when asked, staff always knock on peoples doors” and “We treat them how we would wish to be treated” Personal support and health care needs were included in individual care plans. Separate health action plans were in place and routine health checks were being carried out. Records showed peoples involvement with healthcare professionals including appointments, also the monitoring of general well-being and ill health. Staff had received training in relation to specific health care matters such as epilepsy. Medication storage facilities were satisfactory, advice was offered on the safe storage of controlled drugs. Medication policies and procedures were seen to be available, it was advised copies be kept to hand. All staff had received guidance and training in administration of medication. Medication leaflets from pharmacist were available on all prescribed items. Records seen were mostly clear and up to date; dosage instructions for one item had been checked with GP, but as this discussion had not been recorded, instructions remained unclear. The assessing of peoples ability to manage, or be involved with their medication, also individual protocols for ‘when necessary’ and ‘variable dose’ was discussed with the manager. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good 22 and 23 This judgement has been made using available evidence including a visit to this service. Most policies, procedures and practices provided safeguards for people using the service supported the complaints process. EVIDENCE: The AQAA (Annual Quality Assurance Assessment) completed by the manager, provided a clear indication of Fernleighs’ ethos in providing an open and honest approach in all aspects of service provision. Mention being made that “A culture of honesty is promoted and all complaints are dealt with swiftly and confidentially” The complaints process was discussed with the manager, in particular, enabling keyworkers to support the younger adults in raising complaints, also accessing any available complaints/customer care training. The complaints procedure was included in the homes guide and was written in a ‘user friendly’ style, pictures and symbols had been used to help make accessible to people using the service. The procedure included clear instructions on making a complaint and details of other agencies, including advocacy services and the Commission. One comment in a staff survey was, “Any concerns are passed to the home manager who deals with them” The AQAA provided detailed information about the homes priority to promote the protection of the younger adults, clear recognition being given to the vulnerability of the people accommodated. Staff had been provided with POVA Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 17 (protection of vulnerable adult) training and positive handling training. The younger adults individual safety needs had been assessed and any physical interventions required in their best interest highlighted. Clear records were kept of any incidents of restraint. Systems were in place to monitor and review such interventions. Policies and procedures were in place in relation to safeguarding and protection, including a staff ‘whistle blowing’ procedure. Clear details were noted of the necessary action to be taken and referral procedures. The manager and staff spoken with, expressed a good awareness of safeguarding matters, including the action to be taken in response to any protection issues. As the home was accommodating someone under 18 a Safeguarding Children information pack had been obtained, however, the home needed to develop their own specific policies and procedures, including the appropriate local child protection referral protocols. This information then needed to brought to the attention of the staff team. The AQAA showed that ensuring the staff team are refreshed with available POVA training as a plan for ongoing improvement. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The accommodation provided a comfortable, attractive and clean living environment for people living Fernleigh House. EVIDENCE: Efforts had been made to decorate the home in a bright, homely and contemporary style, furniture and fittings were domestic in style and of a good standard. There was much evidence of attention detail of décor, with coordinating fabrics, floor coverings and accessories such as pictures and cushions. Communal rooms provided enough space for people to spend time on their own or in groups. People living in the home appeared comfortable in their surroundings and were seen to make use of the various areas and facilities. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 19 All bedrooms were single and people had been supported to personalise their own space to reflect their tastes, interests and character. The manager explained that one persons’ family had furnished their room for them. Not all bedrooms had been fitted with an appropriate lock; the value of providing this facility to promote privacy of space was discussed with the manager. One bathroom was seen to be in need of upgrading, the manager had already identified this as an area for improvement and said it would be included in the soon to be devised annual development plan. The home was found to be clean and free from unpleasant odours. Satisfactory laundry equipment and facilities were available. Infection control policies and procedures were available, equipment such as plastic gloves, aprons and anti bacterial hand cleaner was provided. People living at Fernleigh were seen to be supported to make much use of the large enclosed garden, which had equipment such as a trampoline and swings. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that plans were being made to improve outside facilities with a greenhouse and inwardly a sensory room, with soft play area lights and music. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements aimed to provide people using the service with effective and consistent support. EVIDENCE: Throughout the visit, the staff team were seen to provide positive and insightful support; they interacted effectively with the younger adults, interpreting and responding sensitively to their specific needs and wishes. The staff spoken with were enthusiastic and knowledgeable about their role in providing effective individual support for people. Records and discussion showed staff training was being given appropriate attention at Fernleigh. The company had a designated training officer. The training matrix showed training had been provided, was ongoing or being planned for. Some staff had attained NVQ level 2; others had commenced this course of learning. Staff were being offered LDAF (Learning Disability Award Framework) training following their 6 month probationary period. Challenging Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 21 behaviour, medical matters and learning disability training was being provided in–house. One comment in a staff survey was “The training is excellent, and extra training is always available” Staffing rotas were being devised flexibly, to take into account the needs, abilities and routines of the people accommodated. The rota showed various work patterns, influenced by the service users activities and support needs. The manager said there were always between 6 and 9 support staff on duty during the day. There were waking and sleep in night staff and systems in place for on call support. The manager explained the programme of induction training for new staff, this involved classroom learning, general orientation, health and safety matters, and getting to know the younger adults, their individual needs and support processes. Staff surveys indicated the induction training covered all necessary matters. The records kept of the recruitment procedure of the two newest staff indicated appropriate checks and screening had been carried out, references sought and interviews held. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that plans were being made to improve the programme of individual staff training and development. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Management and administration practices were effective in ensuring the home is run for the benefit of the younger adults, staff and visitors. EVIDENCE: The registered manager had worked for Progress Adult Service for 8 years, initially as a support worker, progressing to deputy manager and then registered manager in another home in the organisation. He had been manager at Fernleigh for about 10 months. Andrew Law had attained NVQ level 3 in care and the Registered Managers Award and was due to commence NVQ level 4, promoting independence. In addition, Andrew was a BILD (British Institute of Learning Disabilities) Positive Handling Trainer and had recently Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 23 attended training on ‘Positive approaches to Autistic Spectrum Disorder’. This inspection visit showed the manager was enthusiastic, proactive and competent within his role. The AQAA (annual quality assurance assessment) completed by the manager, included much relevant and detailed information, good practice areas for improvements had been identified. Families of people living at Fernleigh and other relevant people had been enabled to complete satisfaction surveys. Quality assurance was discussed with the manager; including approaches to more effectively involve the younger adults. It was advised the results/findings of quality surveys be reflected within the AQAA process. Arrangements were in place for staff to receive training in safe working practice subjects. All maintence records and installation certificates had been seen as part of the homes registration processes. Systems were in place to record and follow up any heath and safety matters. A health and safety manual was available showing ongoing checks were being carried out. Health and safety risk assessments were available; they had been completed prior to the home being registered to accommodate the younger adults, it was therefore suggested they be reviewed and updated. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 32 (1)(2) Requirement Appropriate policies and procedures must be defined and introduced, to provide the necessary safeguards in relation to children. Timescale for action 25/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations To ensure peoples ‘short term’ goals and any necessary responses and approaches are effectively communicated, systems should be introduced to provide clear written instructions for staff. When a GP is contacted to verify medication dosage instructions, this should be recorded to ensure staff have clear information. Policies should be introduced to guide staff in this practice. To ensure management of medication is safe and appropriate, a regular auditing system should be introduced which covers matters such as records, storage and administration. The assessing of peoples ability to manage, or be involved with their medication. Also, individual protocols for ‘when DS0000070764.V362754.R01.S.doc Version 5.2 Page 26 2. YA20 3. YA20 4. YA20 Fernleigh House 5. YA23 6. YA24 necessary’ and ‘variable dose’ medication should be given further consideration and attention. To ensure all regulations and standards are met, the Care Home Regulations 2001 and National Minimum Standards, Supplementary Standards for young people aged 16 and 17 should be referred to, and any necessary action taken. To promote privacy of space, it is recommended suitable locks, which enable access in the event of emergency and choice of usage, be fitted to all bedroom doors. Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Fernleigh House DS0000070764.V362754.R01.S.doc Version 5.2 Page 28 - 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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