Inspection on 13/10/06 for Church Farm

This inspection was carried out on 13th October 2006.

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 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

Church Farm 08/07/09

Church Farm 01/05/09

Church Farm 11/12/08

Church Farm 03/07/07

Church Farm 06/09/05

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

CARE HOMES FOR OLDER PEOPLE Church Farm Yarmouth Road Hemsby Great Yarmouth Norfolk NR29 4NJ Lead Inspector Maggie Prettyman Unannounced Inspection 13th October 2006 01:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Farm Address Yarmouth Road Hemsby Great Yarmouth Norfolk NR29 4NJ 01493 730181 01493 531599 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) rsonshomes@btopenworld.com R Sons (Homes) Limited Mrs Anne Morley Care Home 40 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (12) of places Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Church Farm offers residential accommodation to a maximum of 40 service users in the registration category of older people. The building is a period residence that has been adapted over the years to meet the needs of older people and extended to include purpose built accommodation. Service users rooms are situated on the ground and first floor of the building. Twenty-four of the rooms have en suite facilities and all others have washbasins with access to WCs and bathrooms close by. There are four separate communal areas and a conservatory, which has been designated a smoking area for staff and residents. The grounds are well maintained comprising of a garden and large car park at the front of the property and a courtyard in the centre of the home. Church Farm is located in the seaside village of Hemsby, 5 miles north of Great Yarmouth. The home is situated in a quiet location away from the main centre of Hemsby and is within walking distance of the local shop. There are very few local facilities, however it is a short drive to the town of Great Yarmouth, which has numerous shops and other facilities. The surrounding areas of Hemsby also offer a number of pubs and restaurants situated on the edge of the broads that can provide some very pleasant outings. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. What the service does well: What has improved since the last inspection? Service user plans have been comprehensively and professionally updated. A four weekly menu is in development. A new call system is being installed to improve safety and electronic audit of service users support. A number of new staff have been appointed to increase the levels of staffing in the home. Staff files are now audited for completion. Staff supervision has changed in nature to be more relevant to the task required. A new contractor has been appointed to provide documented checking of safety systems. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 6 What they could do better: Some of the shortfalls identified during the inspection are due to a vacant management post, which has recently been filled. Two requirements and some recommendations have been made at the end of this report. Requirements made are as follows; • • The statement of purpose and service user guide must be given to service users in an updated form Documentation for staff recruited from an agency must meet the requirements of the care standards Recommendations made are as follows; • • • • • • • The medicine fridge temperature should be checked Naming of garments should be addressed by the service user guide Menus should be provided for service users. The central training record should be completed A staff training and development programme should be formalised Water temperatures should be regularly checked and recorded Accidents and incidents should be audited to identify any preventable patterns and trends 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. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. The service user guide and statement of purpose are currently being updated. Contracts are given to service users after admission to the home A comprehensive needs assessment is conducted for permanent and short stay service users Suitable plans of care are in place to enable service users on short stay to remain independent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide were seen on the computer system in the process of update. It is required that these documents be updated and made available to service users. The manager is considering more accessible forms of presentation such as DVD or web access. Contracts were seen in place on service users files. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 9 Several service user files were seen, both short and long stay service users were found to have clear and appropriate details of needs and plans of care. Short stay service users needs assessments were found to be of a good standard, with details of maintenance of self help skills seen. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. Detailed plans of care are in place for all service users. Health care needs are monitored and met. A safe system of medication administration is in place. Service users privacy and dignity is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several service user files were seen and found to have clear, well-organised plans of care. This was the case for both long stay and respite care service users. Details of health care needs were found in service user plans. Weight is monitored monthly. The manager is considering accessing MUST to ensure comprehensive nutritional screening. Local dentists and GPs are used. The continence advisor is regularly consulted. Signs and symbols are used throughout the home to assist service users with dementia care needs. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 11 The medication trolley and charts were examined and found to be well managed. No service users are currently self-medicating, but facilities are in place for this eventuality. It is recommended that the medication fridge temperature be regularly checked. Post is given to service users or their appointee unopened. Rooms are all named for individual service users. Interactions observed between staff and service users during the inspection were seen to be polite and friendly. Service users consulted confirmed that they are treated with respect at all times. Some confusion exists about responsibility for naming clothes. It is recommended that this be clarified in the service user guide. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Quality in this outcome area is good. A variety of activities take place in the home, but these could be expanded. Service users have a wholesome and appealing diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Outings planned for the summer had to be cancelled because of a corporate decision to limit such activities to 1:1 care. The home has activities that take place on a regular basis and an activities worker is employed one day per week. The manager is currently considering expanding these hours and the range of activities provided. The kitchen was inspected and found to be of a high standard. A gold star environmental health certificate has been recently gained. The chefs and kitchen staff were found to be interested in, and committed to, provision of good quality food. The fortnightly menu is being expanded to four weekly. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 13 No menus are provided for service users, but they are consulted daily about choice and personal preferences. It is recommended that service users be given menus with pictorial presentation to further facilitate access to choice. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Quality in this outcome area is good. Complaints are listened to, taken seriously and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An example of how a complaint has been investigated was seen, and found to be prompt, appropriate and detailed. As an outcome of this complaint the manager intends to use accountability record sheets in the rooms of service users who are unwell. A new call system due to be installed will enable such records to be kept electronically. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality in this outcome area is good. Service users live in a safe, well-maintained environment. Lavatories and washing facilities are accessible. Service users live 9in safe comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated the home to be accessible, well maintained and meeting individual and collective needs in a comfortable and homely way. Toilets and bathrooms were well signed and seen to be clean and comfortable. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 16 Individual bedrooms seen demonstrated that personal possessions are always encouraged in individual service user rooms. Photographs and personal items were seen in all rooms. The tour of the premises demonstrated it to be clean, pleasant and hygienic. Laundry facilities are appropriately sited, and industrial machines ensure appropriate laundry of foul linen. Items were found to be sorted according to washing needs. Individual boxes are in place for all service users clothes. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in this outcome area is good. Numbers and skill mix of staff meet Service users needs. Service users are supported by the homes recruitment procedures. Staff are well trained, but better records of this could be kept. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has appointed new staff to improve its staffing levels. Observation of the home during the inspection demonstrated adequate staffing levels on that day. Examination of staff files demonstrated that a file audit checklist is now in place. A group of new staff has been appointed from a recruitment agency. It is required that the home ensures that all documentation relating to CRB checks and interviews as well as validation of references are provided by the agency. Lists of training were seen in the home. Staff were also observed applying for a forthcoming course. The manager is in the process of developing a training matrix. Training courses are planned, but an overall training programme for the home is yet to be developed. It 9is recommended that a programme of training is produced and work commenced on training records completed. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is good. The home is run by a competent manager. The home is run in the best interests of service users. Staff supervision is in place, but should be more regular. The health, welfare and safety of service users and staff are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the manager demonstrated a good understanding of her role and responsibilities. The assistant manager’s post has been vacant for some time, but has recently been filled. A further assistant manager will also be appointed to strengthen the management team, and enable administrative and supervisory tasks to be completed. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 19 A quality assurance survey has been completed by the home, and requests and comments made responded to. Regular meetings for relatives are in place. This is a forum for matters to be raised and information about the needs and care of older people shared. Records of staff supervision were seen. These demonstrated that although in place, it is irregular. This will be rectified by the appointment of the assistant managers. The style of supervision has been adapted in response to recommendations in the previous report. Statutory health and safety training takes place. Hoists were found to be regularly maintained. Hazardous substances are appropriately stored. A new contractor is providing evidence of checks on safety systems. It is recommended that water temperatures are routinely checked and recorded. It is also recommended that an audit of accidents and incidents be kept to identify any preventable patterns and trends. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5 Requirement The Service user Guide and Statement of purpose must be updated and provided for current and prospective service users. The home must ensure that documentary validation of checks carried out by the recruitment agency are held on staff files. Timescale for action 31/12/06 2 OP29 Schedule 2 30/11/06 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. 2. 3. 4 Refer to Standard OP9 OP30 OP30 OP10 Good Practice Recommendations Repeated recommendation It is recommended that the home introduce a system for monitoring the medication fridge temperature. Repeated recommendation. It is recommended that a staff training and development programme be produced. Repeated recommendation. It is recommended that a central training record be maintained. It is recommended that the system of naming clothes be included in the service user guide. DS0000064306.V316520.R01.S.doc Version 5.2 Page 22 Church Farm 5. 6. 7. OP15 OP38 OP38 It is recommended that menus be provided for service users, supported by pictorial illustrations to facilitate service user choice. It is recommended that water temperatures are regularly checked and recorded. It is recommended that an audit of accidents and incidents be kept to identify patterns and trends that may be eliminated. Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Church Farm DS0000064306.V316520.R01.S.doc Version 5.2 Page 24 - 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. 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