Inspection on 12/07/05 for 29 Firgrove Hill

This inspection was carried out on 12th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

29 Firgrove Hill 29/05/07

29 Firgrove Hill 26/01/06

29 Firgrove Hill 19/07/04

29 Firgrove Hill 21/04/04

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

CARE HOME ADULTS 18-65 Firgrove Hill (29) 29 Firgrove Hill Farnham Surrey GU9 8LN Lead Inspector Kerry Fell Unannounced 12 July 2005 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 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 Stationary 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. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Firgrove Hill (29) Address 29 Firgrove Hil Farmham Surrey GU9 8LN 01252 721580 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mencap National Centre Mrs Deborah Alison Skidmore Care Home 5 Category(ies) of LD Learning disability - 5 registration, with number of places Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Of the 5 residents accommodated 1 resident may fall within the category of LD(E), Learning Disabilities/Older Person. Date implemented: 1 April 2002 The age/age range of the persons to be accommodated will be: 18 - 64 AND ONE PERSON AGED OVER 65 YEARS. Date implemented: 1 April 2002 The named condition of registration in the CSCI letter dated 11th April 2005. Date implemented: 7 April 2005 Date of last inspection 19 July 2004 Brief Description of the Service: 29 Firgrove Hill is a detached Victorian house situated in the centre of Farnham, just off a busy road and within easy access of the town centre. New Era Ltd own the property and Mencap manages the property. The home provides a registered service that offers personal care to five adults with learning disabilities under 65 years of age. Accommodation is provided in 5 large single occupancy rooms that are on the two upper floors. The home has two bathrooms available. There is a communal lounge, kitchen/diner and a large garden available for use by the service users. Some parking is available at the front of the house. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection for the inspection year 2005/2006. The inspection was an unannounced inspection, which means that neither the staff nor the service users were aware that it was going to take place. The inspection undertaken by Mrs Kerry Fell commenced at 14.00 and took 3 hours and 15 minutes to complete. The inspection involved a tour of the premises; observation of a sample of service users care plans and risk assessments, observation of health and safety records, the complaints log, personnel files, and quality assurance documentation. The Inspector met all of the service users resident at Firgrove Hill at the time of the inspection, and four service users were happy to be interviewed by the inspector. One service user was happy, when asked to show the inspector their bedroom. What the service does well: What has improved since the last inspection? A great deal of work has been done to meet the requirements made at the last inspection. Care plans have been updated and records now detail when these have been reviewed. Likewise, risk assessments have been reviewed and updated. Staff files were available for inspection, and it was observed that these records contained references, evidence of identification and original copies of criminal record bureau checks. The Manager has registered with the CSCI Surrey Local Office since the last inspection and is completing the NVQ level 4 in Care and the Registered Managers Award. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 6 The Statement of Purpose and service user guide have been reviewed and updated since the last inspection, although some additional work is required. Service users had been supported by relatives or members of staff to complete a service user-friendly Mencap questionnaire about the service they received. Those responses observed were positive. 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. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2, & 5 The home’s statement of purpose has now been updated and a service userfriendly service user guide was available. The home had endeavoured to obtain the original pre-admission assessment documents and contracts. EVIDENCE: The statement of purpose and service user guide had been reviewed as required at the last inspection. A copy of these documents must be forwarded to the CSCI Surrey Local Office. The statement of purpose contains a picture version of the complaints procedure. The statement of purpose must include the home’s fire procedures rather than the generic fire policy. The statement of purpose was observed to be in a service user-friendly format. A copy of this document must be provided to each service user with an individualised copy of their terms and conditions. The Inspector observed letters on the service users files that provided evidence that the Manager had written to care managers requesting copies of the initial preadmission assessments and copies of contracts. The Manager advised the inspector that the care managers had informed them that when the service users were admitted, several years ago, there would not have been any assessments completed prior to admission. However evidence of ongoing review and assessment of need were available. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 9 The home does not currently have any vacancies, and the last admission was eighteen months ago. There is again evidence on the service user’s file that the Manager has requested a copy of their contract and initial pre-admission assessment. This service user was admitted to Firgrove Hill as an emergency placement from another Mencap home. The inspector observed that service users had tenancy agreements on their files from New Era who own the building. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,8,9 Care plans and risk assessments were up to date and had been regularly reviewed. EVIDENCE: The inspector observed from the four service user files sampled that the care plans had been updated as required. Evidence was also observed on the file that these plans were reviewed on a regular basis, some of which had been last reviewed in late June 2005. Members of staff advised the Inspector that the service users were involved in the development of their care plans. Some service users spoken to could not remember being involved in the development of their care plans, however the service users did state that they were able to let their key workers know about their likes, dislikes and needs. The inspector was provided with a copy of a Mencap picture questionnaire that the service users completed with the assistance of relatives or key workers. The questionnaires were in a simple and user-friendly format. Responses observed in these questionnaires were positive. Service users spoken to during the inspection confirmed that they were happy living at Firgrove Hill, and that they felt supported. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 11 The inspector observed from service user’s files that the risk assessments had been reviewed. Again there was evidence on these files that the risk assessments had been regularly reviewed. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 Service users are supported to take part in meaningful activities, and are supported to be as independent as possible. EVIDENCE: All of the service users returned from activities during the inspection. The service users informed the inspector that they had either been at work, adult education or assisting in daily chores, for example food shopping. Each service user had a range of activities available to them. One service user was due to go to complete voluntary work on the evening of the inspection, other activities were detailed in the care plans and statutory review documents. Evidence was also observed in review documents and care plans that service users attended social groups and community activities, for example service users informed that inspector that they went to line dancing. It was also recorded that service users were supported to attend local churches, and some had been on holiday since the last inspection. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 13 Care plans detailed the important people in service user’s lives, and where appropriate service users are supported to visit friends or have friends visit them. Members of staff were arranging a visit for tea at a friend’s home for one service user during the inspection. It was observed that the service users residing at Firgrove Hill were quite independent. Service users were completing personal chores, for example laundry. One service user was due to assist with cooking the evening meal, but decided not to. Some service users spoken to expressed that they wished to move to supported living, or to be more independent. All service users receive their benefits by direct payments into their own bank accounts. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,&21 Records and care plans detail the wishes of service users with regard to their lives, routines, and support. Healthcare appointments and input are also recorded. EVIDENCE: The inspector observed from the care plans that guidance is available to direct staff on how to support the service users with personal care, for example bathing guidelines. Service users have designated key workers, and relationships observed during the inspection were positive. Routines within the home were observed to be flexible, and service users were freely choosing what they wanted to do on returning to the home. All healthcare appointments attended since the last inspection had been recorded on forms in the service users file. Theses healthcare records detailed that service users had attended the dentist, optician and GP as required, and where appropriate service users had received input from specialist health professionals for example psychiatry. The Manager advised the inspector that the wishes of all of the service users and their relatives had been gained with regard to ageing, illness and in the event of their death. These wishes were detailed on the service user’s file. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Members of staff support service users to raise concerns. EVIDENCE: The inspector observed that pictorial complaints procedures were displayed around the home, and is detailed in the statement of purpose. A complaint logbook had been developed as required. Both members of staff and service users who were spoken to advised the inspector that service users had not needed and did not want to make formal complaints. However, to recognise concerns that had been raised by the service users the rear of the logbook is used to record “informal” complaints. The complaint and response had been recorded. The Manager must clarify with members of staff what their understanding of a complaint/informal complaint is, to ensure that service users concerns and complaints are always heard and dealt with appropriately. The inspector observed training records on personnel files. It was recorded that staff had received training in protection from abuse from Mencap. The policies and procedures with regard to the protection of vulnerable adults were not observed at this inspection but will be looked at in more detail at the next inspection. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 Service users continued to like living at the home, and had been involved in choosing the schemes for redecoration. EVIDENCE: The home was observed to be neat and orderly. Service users spoken to during the inspection confirmed that the lounge had recently been redecorated and that new sofas had been purchased. The service users stated that they had been involved in choosing the colour scheme. All of the service users spoken to during the inspection stated that they liked living at the home, and when asked the service users confirmed that they liked their bedrooms. The rear gate had now been fitted to the rear of the house as required. One service user showed the inspector their bedroom, which was highly personalised. The bedroom had been furnished to meet their needs. The bedroom was observed to be large and provided ample space for the service user to keep their personal items. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 36 Personnel files are now available at the home, and were well maintained. EVIDENCE: Personnel files were now held at the home. Those files sampled contained references, identification documents and original Criminal Records Bureau certificates. Supervision contracts and records were held on the staff personnel files. The inspector observed that a chart of supervision dates was kept on the personnel file. This was signed and dated by both the manager and the member of staff. The Manager confirmed that they had been receiving regular supervision until recently when their line manager has been away from work. The Manager confirmed that mechanisms of support had been put in place, and that although they had not been receiving monthly supervision; they had received supervision in May and were due a supervision session the week following the inspection. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 EVIDENCE: The Manager is registered and in the process of completing the NVQ Level 4 in Care and Management, and informed the inspector that they are progressing well with the course. The Manager showed the inspector details of the courses attended since the last inspection. The home had received a service review by Mencap in January 2005, which clearly identified areas for improvement and areas of good practice. One recommendation from this review was a requirement for training in managing finances. The Manager confirmed that they had not received this training. The Manager must therefore receive training in the management of finances. Service users had also been asked to complete questionnaires. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 19 Records had been updated since the last inspection, and there was evidence of regular review. The inspector observed members of staff completing the hot water temperature checks. Members of staff were also keeping records of all other health and safety checks being completed. The inspector observed that the fire risk assessment held by the home was dated March 2004. This must be reviewed and updated without delay and a copy of the updated risk assessment must be sent to the CSCI Surrey Local Office. Mencap have introduced a fire safety CD-rom to train staff. The Manager must confirm with the Fire Safety Officer that this is an acceptable way to train staff. Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Firgrove Hill (29) Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 3 2 x H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The statement of purpose must include the home’s fire procedures rather than the generic fire policy. A copy of the service user guide must be provided to each service user with an individualised copy of their terms and conditions. The Manager must clarify with members of staff what their understanding of a complaint/informal complaint is, to ensure that service users concerns and complaints are always heard and dealt with appropriately. The Manager must receive training in the management of finances. The fire risk assessment must be reviewed and updated without delay and a copy of the updated risk assessment must be sent to the CSCI Surrey Local Office. The Manager must confirm with the Fire Safety Officer that training staff by a fire safety CDrom is acceptable. Timescale for action 12/08/05 2. 1 5 12/08/05 3. 22 22 12/08/05 4. 5. 37 42 9(1), 18(1)(c ) i, 20. 23 (4) 12/09/05 12/08/05 6. 42 23(4) 12/08/05 Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 22 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 Good Practice Recommendations Firgrove Hill (29) H58 H09 s13479 29 Firgrove Hill v238219 120705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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. 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