Inspection on 29/05/07 for 29 Firgrove Hill

This inspection was carried out on 29th May 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Firgrove Hill 26/01/06

29 Firgrove Hill 12/07/05

29 Firgrove Hill 19/07/04

29 Firgrove Hill 21/04/04

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Southfields

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33 St John`s Church Road

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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 Sarah MacLennan Unannounced Inspection 29th May 2007 09:30 Firgrove Hill (29) DS0000013479.V339415.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 Firgrove Hill (29) DS0000013479.V339415.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. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firgrove Hill (29) Address 29 Firgrove Hill Farnham Surrey GU9 8LN 01252 721580 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) www.mencap.org.uk Royal Mencap Society Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 5 residents accommodated 1 resident may fall within the category of LD(E), Learning Disabilities/Older Person The age/age range of the persons to be accommodated will be: 18 64 AND ONE PERSON AGED OVER 65 YEARS The named condition of registration in the CSCI letter dated 11th April 2005. 26th January 2006 Date of last inspection 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. The property is owned by New Era Ltd and managed by Mencap. The home provides accommodation and personal care to five adults with learning disabilities under the age of 65 years. 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) DS0000013479.V339415.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit formed part of the key inspection process and took place over 5½ hours commencing at 09:30 and ending at 15:00. Sarah MacLennan, Regulation Inspector, carried out the visit. Ms Ollie Fielder, the Registered Manager, was present throughout the inspection. As part of the inspection process a partial tour of the premises took place. Various written records were examined, including care plans and service user assessments, staff personnel files, samples of staff training records, the complaints record, the medication storage facilities and the medication administration records. The inspector spoke to a number of service users. Some staff members were spoken to during the course of the inspection. Some of the comments made to the inspector are quoted within this report. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the visit. What the service does well: What has improved since the last inspection? There has been a significant change of staff since the last inspection. The inspector was informed that the home now had a stable staff team. The area to the front of the home near the main door has been resurfaced to prevent the risk of flooding whenever it rained. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 6 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. Firgrove Hill (29) DS0000013479.V339415.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 Firgrove Hill (29) DS0000013479.V339415.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 home has not had any new service users admitted; therefore these standards were not fully assessed. EVIDENCE: No new service users have been admitted to the home since the previous inspection. Discussion with the registered manager evidenced that she would carry out a full and comprehensive pre-admission assessment. There was a printed form in place that would be used to conduct a pre-admission assessment. The home is currently in the process of assisting a service user to ‘move on’ to a supported living placement as it is felt that it would be a more suitable environment to meet his needs. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 9 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 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are in place and risks to health and safety of service users are assessed. EVIDENCE: Two service users’ care plans were looked at. The service users had person centred plans that were detailed and comprehensive. They clearly demonstrated how the home meets the individual needs of the service users. Conversation with staff and service users evidenced that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed. When asked if they received the support they required service user comments included ‘I like it here’ and ‘I can choose what I do’. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 10 Samples of risk assessments were seen and included topics such as, bathing, cooking, accessing the community, use of electrical equipment and fire evacuation. The risk assessments appeared comprehensive. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 11 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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities enables service users to lead a full and active life and participate in the local community. Meals are well balanced, varied and chosen by the service users. EVIDENCE: From examination of the service user recorded and discussion with staff and service users it was apparent that service users are encouraged and enabled to live a full life and to partake in age related activities such as having meals out, attending college of further education and two service users have part time jobs. Service users spoken to gave examples of activities that they had recently enjoyed. Service users participate in the local community. They attend local facilities including shopping centres, pubs, restaurants and cafes. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 12 Service users are actively involved in the day to day running of the home. They have individual responsibility for some of the household chores including laying the table, recycling and washing the kitchen floor. Conversation with staff and service users evidenced that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed. Staff were observed to treat the service users in a calm and confident manner and with respect. The service users take it in turns to choose the main meal of the day. They are then supported to cook the meal. The weekly menu is displayed in the dining area and also lists which service user will be preparing each meal. Alternatives to the main meal choice are always available. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 13 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 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health needs are met and they receive the support they require. The medication administration records were not satisfactory. EVIDENCE: Staff spoken to were aware of the guidance and support required by the service users. Service users stated that the staff were able to meet their needs. Service users were supported and facilitated to take control of their healthcare. All service users were registered with a local GP and had access to a variety of other healthcare professionals including dentists and opticians. All service users spoken to stated that their views and needs were listened to. The medication policy and storage facilities were seen and satisfactory. The medication administration records were examined. It was noted that one service user’s chart had paper detailing medication changes Sellotaped over the original entry. This is not safe practice and a requirement has been made. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 14 A full record of all medication received by the home, specifically when a service user had been discharged from hospital, had not been maintained. The home had links with a local pharmacist who is available to offer advice if required. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a simple and accessible complaints procedure. The policies and procedures in place to protect service users from harm require updating. EVIDENCE: The home had a simple and accessible complaints procedure. Service users spoken to during the inspection were aware of the complaints procedure, and felt confident about using the process. Two complaints had been received since the last inspection and had been appropriately investigated and recorded. The home had an up to date copy of Surrey’s Multi-Agency Procedure for Vulnerable Adults. The home also had several adult protection policies. The home’s policy stated that an incident of a non-serious nature may be investigated internally, it is required that this policy is clarified, as the term ‘non-serious’ is open to individual interpretation. The whistle-blowing policy also requires updating to clearly state that all allegations or suspicions of abuse are reported to Social Services. Staff had received training in the protection of vulnerable adults. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and hygienic and provides an environment suitable for the needs of the service users. EVIDENCE: The inspector toured areas of the home. Staff informed the inspector that service users had a sense of ownership of their home. Comments from service users included, ‘yes, I like my room’ and ‘it’s nice’. The home was suitable for the needs of the service users. The décor was domestic in nature and general standards of maintenance were good. It was seen to be clean, tidy and free from offensive odours. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s recruitment policy and practices and are supported by competent and qualified staff. EVIDENCE: Samples of the staff’s training records were seen. Staff had received training in protection of vulnerable adults, first aid, infection control, manual handling, medication and food hygiene as well as service user specific training, including epilepsy. Service users spoken with felt that the staff were appropriately trained and competent. New staff members receive a full and comprehensive induction that includes ‘shadowing’ an existing staff member for six weeks. The home had had a complete change of staff since the previous inspection. Samples of staff files were seen and found to contain the required information and documents specified in paragraphs 1 – 9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000(Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 18 Staff morale appeared high and the workforce dedicated. All staff spoken to stated how much they enjoyed their jobs. Discussion with the manager evidenced that 25 of staff have completed NVQ level 2 or above and a further three staff members are due to start their NVQ training in September. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 19 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 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from an open, positive and inclusive atmosphere. The home has effective systems in place to monitor the quality of care and services provided and systems are in place to protect the health, safety and welfare of service users. EVIDENCE: The registered manager demonstrated a thorough knowledge and awareness of the service users’ needs. Service users were seen to interact readily with the registered manager. An open and inclusive atmosphere was evident within the home. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 20 All staff and service users appeared happy, contented and relaxed with the inspection process. The atmosphere within the home during the inspection was lively and cheerful. The registered manager stated that various quality to ensure the services users had a forum for airing monthly keyworker meetings and house meetings, surveys and staff supervision. All service users views were listened to and taken seriously. audit systems were in place their views. These included comprehensive service user spoken with felt that their The registered manager is aware of the need to maintain a safe environment for service users and staff. Required policies, procedures and safety checks were in place; samples of which were seen. Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 21 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 X 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 3 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 Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 22 No 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 YA20 Regulation 13 (2) Requirement The registered person must ensure that a full and accurate record of all medication given to service users is maintained. The practice of Sellotaping paper detailing medication changes over the original entry must be ceased. A full record of all medication received by the home, specifically when a service user had been discharged from hospital, must be maintained. The registered person must ensure that the home’s policy to ensure the protection of vulnerable adults is updated to include clarification of the term ‘non-serious’ and to state that all allegations or suspicions of abuse should be reported to Social Services. Timescale for action 29/06/07 2 YA23 13 (6) 29/07/07 Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Firgrove Hill (29) DS0000013479.V339415.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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