Inspection on 23/05/05 for Farnham Common House

This inspection was carried out on 23rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Farnham Common House 05/06/07

Farnham Common House 03/05/06

Farnham Common House 14/11/05

Farnham Common House 15/06/05

Farnham Common House 30/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

Care Home For Older People Farnham Common House Beaconsfield Road Farnham Common Slough Bucks SL2 3HU Unannounced Inspection 23rd March 2005 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. V175348 mm/ps js ESTABLISHMENT INFORMATION Name of establishment Farnham Common House Address Beaconsfield Road, Farnham Common, Slough, Bucks, SL2 3HU Email address Name of registered provider(s)/company (if applicable) The Fremantle Trust Name of registered manager (if applicable) Mrs Yvonne Peace Type of registration Care Home No. of places registered (if applicable) 50 Tel No: 01753 669900 Fax No: Category(ies) of registration, with (number of places) Dementia - over 65 years of age (25), Old age, not falling within any other category (25) Registration number H530002015 Date first registered 14th May 2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection Date of latest registration certificate 14th May 2004 NO NO 1 Oct 2004 If Yes refer to Part C Farnham Common House Page 1 V175348 mm/ps js Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 23rd March 2005 09:30 am Mike Murphy Gill Wooldridge ID Code 130017 096522 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Farnham Common House Page 2 V175348 mm/ps js CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Farnham Common House Page 3 V175348 mm/ps js INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Farnham Common House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Provider’s response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates. Farnham Common House Page 4 V175348 mm/ps js BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Farnham Common House opened in May 2004. It is a care home providing personal care and accommodation for 50 older people. The development is the result of a partnership between The Fremantle Trust, Beacon Housing Association and Buckinghamshire County Council. The service is run by The Fremantle Trust. The home is located in Farnham Common, Buckinghamshire. The home is divided into four houses – two of ten places and two of fifteen places. One house on the ground floor is dedicated to the care of people with dementia. The home is purpose built and provides a good quality, well equipped and spacious environment for service users. All bedrooms are single and all have en-suite facilities comprising wc, sink and shower. The home is set in compact but pleasant grounds. There is usually sufficient parking for staff and visitors cars. Farnham Common House Page 5 V175348 mm/ps js PART A SUMMARY OF INSPECTION FINDINGS INSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Farnham Common House Page 6 V175348 mm/ps js This unannounced inspection was conducted by two inspectors on a mid week afternoon in March 2005. The manager was off duty and the deputy manager facilitated the inspection. Inspectors were joined later in the afternoon by the service manager who happened to be visiting the home before the Easter weekend. The inspection offered an opportunity to consider developments in the home as it neared the end of its first year of operation. As the inspectors recorded in their report of the announced inspection in September 2004 the first year of a new home can present unexpected challenges to managers, staff and service users and Farnham Common House was no exception. On the evidence of this unannounced inspection the challenges have been well managed and the home is in a good position to develop a service of the quality to which it aspires. All of the requirements and recommendations of the announced inspection either had been met or were being addressed. This inspection took place before the end of the timescales for action on three requirements and inspectors were given a progress report with regard to these. Choice of Home (Standards 1-6) 1 of 3 standards assessed was ‘met’. 2 of 3 standards assessed were ‘nearly met’. 2 standards were not assessed. 1 standard was ‘not applicable’. The service user’s guide was being reviewed and updated by the registered manager to fully conform to this standard. Inspectors were informed that the home is addressing the matter of staff training and supervision with regard to assessment. In examining records and in discussions with staff inspectors continued to find an uneven picture. In some care plans, recorded assessments appeared comprehensive, were clearly recorded and formed a sound basis for the plan of care. Others were less thorough. In one case significant information was not recorded in the assessment and in consequence some staff were unaware of a medical condition which was not included in the care plan. Prospective service users may have a trial period of six weeks which can be extended in some circumstances. Health and Personal Care (Standards 7-11) 1 of 4 standards assessed was ‘met’. 3 of 4 standards assessed were ‘nearly met’. 1 standard was not assessed. All service users have a care plan. The structure of care plans is comprehensive but complex. Practice in the home remains uneven but inspectors felt that there were signs of improvement since the last inspection –particular examples being a night care plan which clearly recorded the wishes of the service user, and more evidence of staff recording service users likes and dislikes. On the other hand there were gaps between needs identified at assessment and a plan of care to meet those needs. For example, a concern regarding a pressure area in the ‘handover book’ was not recorded in the record of the service user concerned. The recording of service users weights was inconsistent. A high proportion of daily entries consisted of brief notes such as ‘ate well’, ‘had a good day’ or ‘slept well’. The standard of practice would appear to depend heavily on the skills of individual staff and while this may be inevitable, inspectors felt that the extent of the variation found on this inspection will require the ongoing attention of supervisors and managers supported by the training department. Staff acknowledged the efforts to date of the registered manager on improving care planning practice. All service users are registered with a local GP practice and the Farnham Common House Page 7 V175348 mm/ps js home receives regular visits from district nurses. Service users appeared well cared for and described staff as caring and helpful. There seemed to be good relationship between staff and service users. One service user who had been in the home for five weeks described it as “Brilliant – lovely room – I get all the care I want”. Inspectors received mixed reports on the food but it was generally considered to be good. Arrangements for maintaining privacy and dignity are good and personal care is carried out in bedrooms or bathrooms. The home has a policy and procedure governing the administration of medicines. Medicines are supplied by Boots Chemists who also carry out periodic audit. The home has obtained a copy of the Royal Pharmaceutical Society’s Guidelines on the storage and administration of medicines in care home and nursing homes. Staff involved in administration were familiar with the policy and had received relevant training. Medicine Administration Records (MARS) were generally in order but in one unit the inspector noted that staff had signed on top of an earlier signature and had scribbled over an entry on the chart. The home should have a list of the signatures of staff who are authorised to administer medicines. Daily Life and Social Activities (Standards 12-15) 2 of 2 standards assessed were ‘met’. 2 standards were not assessed. The daily routines of the home are becoming more established and service users may attend a range of activities. Reports on the food from service users was generally favourable. Adjustments to staffing had been made to enable staff working with people with higher needs to have time to support them at mealtimes. It was reported that the ‘communal room’ on the ground floor was now being used more and some service users talked of meetings and games that are held there. On the afternoon of the inspection service users tended to sit in the house lounges reading, chatting or watching television. The home has now recruited a Leisure Co-ordinator for 20 hours a week. Complaints and Protection (Standards 16-18) These standards were not assessed on this unannounced inspection. All three were fully met at the announced inspection in September 2004. The home is required to conform to the Fremantle Trust’ policies and procedures. Environment (Standards 19-26) 5 of 5 standards assessed were ‘met’. 3 standards were not assessed. The home is a new building which had been operational for just over ten months. All areas visited were clean and tidy and free of unpleasant odours. Inspectors were informed that the home’s handyman had fitted additional grab rails in some en-suite showers. The home was experiencing difficulty on occasions in getting a timely response to maintenance requests but this matter was being discussed with the partner housing association. The kitchens and dining rooms in each of the houses were clean and orderly. One inspector wondered if the main corridor on the first floor could be broken up a little through the use of plants, furniture, pictures and objects (though not to the extent that they would pose a hazard) in order to reduce what was experienced as a long, wide and rather empty space. The size of the bedrooms and en-suite rooms are appreciated by service users. Staff appreciated the better environment. Some areas are still sparsely used outside of organised activities. The garden is accessible from the ground floor. Overall, inspectors gained the impression that service users and staff were settling down well in what is still a new building. Farnham Common House Page 8 V175348 mm/ps js Staffing (Standards 27-30) 1 of 2 standards assessed was ‘met’. 1 of 2 standards assessed was ‘nearly met’. 2 standards were not assessed. At the time of the inspection nine staff were on duty. Some adjustments to staffing had been made since the last inspection and this was being kept under review. Additional staff had been made available at mealtimes to provide support to service users in ‘House 1’. Houses 2 and 4 continue to be without staff during the staff report handover period and solutions to this were being explored. The situation in ‘House 1’ in particular appeared to have improved considerably since the last inspection. A part-time leisure co-ordinator had been appointed. Two new domestic staff were due to start. Training needs had been identified - in particular in relation to dementia - and staff were supported in attending in-house training courses. Staff reported that the home was gradually developing its own identity and that attachments to the former homes – Beechlands and the previous Farnham Common House – may be beginning to weaken. Inspectors were informed that the arrangements for transporting staff to High Wycombe will continue for at least another twelve months. Management and Administration (Standards 31-38) Standards in this section were not fully assessed on this unannounced inspection. Inspectors discussed matters in general terms with the deputy manager and service manager. Overall, inspectors gained a much more favourable impression on the home on this inspection and the efforts of managers in achieving this is acknowledged. The home is due to have an internal quality assurance audit in 2005 and this should support managers to identify strengths and weaknesses and set in course a programme of action to address these. Staff supervision and appraisal are in place and a sample of staff development folders were examined. Each folder contained a job description, person specification, induction and training programme, development reviews, training and development needs and supervision notes. Staff benefit from the Fremantle Trust’s training programme but inspectors recommend that additional training and supervision is required to address training needs in assessment and care planning. The inspectors would like to thank the service users, staff and managers for their time and hospitality over the course of this inspection. Farnham Common House Page 9 V175348 mm/ps js Requirements from last Inspection visit fully actioned? If No please list below NO STATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action 1 5 (1)(2)(3) 1.2 1.3 The Registered Manager is required to review and update the service use’s guide to include all of the information required under this regulation. Taking into account the potential adverse effect on service users the Registered Manager is required to review the practice of large numbers of staff attending handover meetings at the same time. February 28 2005 8 18 27 January 31 2005 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Met (Yes / No) Farnham Common House Page 10 V175348 mm/ps js STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered manager is required to maintain a list of signatures of staff who are authorised to administer medicines. Each signature must include the date on which it was entered on the list. April 30 2005 1 13(2) 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * It is recommended that the registered manager request district nurses to either leave a copy of their care plan with the home or to give clear instructions to staff with regard to care given including the actions to take when dressings become wet or soiled. 1 7 Farnham Common House Page 11 V175348 mm/ps js PART B INSPECTION METHODS & FINDINGS YES YES NO YES YES NO NO NO NO NO YES NO YES YES NO NO NO YES NO YES 10 0 0 NO YES YES YES 43 0 24/3/05 13.30 3.5 The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) Farnham Common House Page 12 V175348 mm/ps js The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Farnham Common House Page 13 V175348 mm/ps js Choice of Home The intended outcomes for the following set of standards are: • • • • • • 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. Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) X To (£) X Any charges for extras NO 0 If yes, please state what the extra’s are: Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Farnham Common House Page 14 V175348 mm/ps js Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 15 V175348 mm/ps js Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not offer intermediate care. Farnham Common House Page 16 V175348 mm/ps js Health and Personal Care The intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. 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. Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X X 2 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 17 V175348 mm/ps js Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? See summary for findings on this standard on this unannounced inspection. Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection but was fully met on the announced inspection in September 2004. Farnham Common House Page 18 V175348 mm/ps js Daily Life and Social Activities The intended outcomes for the following set of standards are: • • • • 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. Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 19 V175348 mm/ps js Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 20 V175348 mm/ps js Complaints and Protection The intended outcomes for the following set of standards are: • • • 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. Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence X X X X X X X 0 Standard met? This standard was not assessed on this unannounced inspection but was fully met on the announced inspection in September 2004. Farnham Common House Page 21 V175348 mm/ps js Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection but was fully met on the announced inspection in September 2004. Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists X X 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection but was fully met on the announced inspection in September 2004. Farnham Common House Page 22 V175348 mm/ps js Environment The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 23 V175348 mm/ps js Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Farnham Common House Page 24 V175348 mm/ps js Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 50 50 0 0 3 50 X X 0 0 0 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 25 V175348 mm/ps js Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Farnham Common House Page 26 V175348 mm/ps js Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Staffing The intended outcomes for the following set of standards are: • • • • 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. Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Farnham Common House X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X 0 X X Page 27 V175348 mm/ps js Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. 2 Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 X X 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Farnham Common House Page 28 V175348 mm/ps js Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? See summary for findings on this standard on this unannounced inspection. Farnham Common House Page 29 V175348 mm/ps js Management and Administration The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this unannounced inspection. Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this unannounced inspection. Farnham Common House Page 30 V175348 mm/ps js Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this unannounced inspection. Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. 0 X X X Farnham Common House Page 31 V175348 mm/ps js Standard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this unannounced inspection. Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not assessed on this unannounced inspection. Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not fully assessed on this unannounced inspection. Farnham Common House Page 32 V175348 mm/ps js PART C (where applicable) COMPLIANCE WITH CONDITIONS Condition Comments Compliance Condition Comments Compliance Condition Comments Compliance Regulatory Mike Murphy Inspector Regulation Manager Clive Wooldridge Date Signature Signature Public reports It should be noted that all CSCI inspection reports are public documents. Farnham Common House Page 33 V175348 mm/ps js PART D D.1 PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on the 23rd of March 2005,of inspection here and any factual inaccuracies: Please limit your comments to one side of A4 if possible Farnham Common House Page 34 V175348 mm/ps js Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NO Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report YES NO Provider comments are available on file at the Area Office but have not YES been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YES D.2 Action plan was received at the point of publication YES Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YES NO NO Other: enter details here NO Farnham Common House Page 35 V175348 mm/ps js D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I of Farnham Common House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Farnham Common House am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable. Farnham Common House Page 36 V175348 mm/ps js Farnham Common House / 23rd March 2005 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000060674.V175348.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!