Inspection on 06/09/05 for Church Farm

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 13/10/06

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 NR29 4NJ Lead Inspector Kim Patience Announced 06 September 2005 9:30 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 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 I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Church Farm Address Yarmouth Road, Hemsby, Great Yarmouth, Norfolk, NR29 4NJ 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) 01493 730181 01493 531599 R Sons (Homes) Limited Mrs Anne Morley Care Home 40 Category(ies) of DE(E) Dementia - over 65 registration, with number of places CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Forty (40) Older People may be accommodated up to two (2) of whom may have dementia. Maximum number not to exceed 40. Date of last inspection 20 April 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 I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took approximately 5.45 hrs to complete. The manager and her deputy were present throughout the inspection and helpful in providing information that was required to assess the standards and in facilitating the smooth running of the inspection. In order to assess the standards, staff and service users were interviewed, records were inspected and a tour of the premises was undertaken. The home has experienced a change in ownership and the new owner has introduced a number of improvements to the service, these were taken it account during the inspection and are described in the body of the report. What the service does well: What has improved since the last inspection? What they could do better: The management need to make improvements to care planning and must ensure that care plans are in place for each individual. The management must ensure that staffing levels are adequate. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 6 Improvements could be made to training records, staff files and staff supervision. 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. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 N/A EVIDENCE: N/A CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Each service user has an individual plan of care, however the home cannot fully demonstrate that service users care needs have been considered due to the lack of a care plan. The management can demonstrate that service users health needs are met, by evidence of record keeping in this respect. The home has systems in place to ensure the safe administration and storage of medication. Service users are treated with respect and their privacy and dignity is respected. EVIDENCE: A number of service user plans were inspected. Due to the change in ownership of the home and the implementation of new procedures and documentation some of the records were found to be incomplete. While they contained detailed information in respect of each individual, there was no single care plan that stated the need and how it should be met. The manager CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 10 was able to produce a suitable format for care planning that will be implemented immediately. It is required that the home ensures that care plans are completed for each resident and that they provide clear information on which care practice can be based. See requirements Other records seen within the service users plan showed evidence that peoples health care needs were being met and the home has had the support and advice of the district nursing services in order to devise a system for monitoring the incidence of pressure sores. Records of other forms of medical intervention were seen, such as GP, district nurses and chiropodist visits. Medication requirements were clearly recorded and kept under review. Evidence of reviews in respect of the overall plan of care could be seen, however, in some cases the last review was June 05. Care plans should be reviewed on a monthly basis. See recommendations The home has a policy and procedure in place to support the safe storage and administration of medicines. The nomad system used at the home is supplied by the local pharmacy who recently provided new containers from which the medication is administered. This was in response to the home expressing concern about the safety of the old containers. The medication administration charts were inspected and found to be in order. The home has a refrigerator for those medicines that require storage at a lower temperature, however had no way of monitoring the temperature to ensure it is kept at the required level. It is recommended that a thermometer is provided and that a record of the temperature is maintained. See recommendations. All staff with the responsibility of administering medicines are provided with training and their practice is monitored on a regular basis. In respect of privacy and dignity being upheld, service users spoken with talked of staff carrying out their duties in a respectful manner. They always knocked before entering the room and used an appropriate form of address. Service users were able to see visitors in the privacy of their own rooms and could choose where to see their GP. Records show that the needs of service users this respect were being taken into account. Their preferred mode of address was recorded and their preferences in respect of the delivery of care were noted. Staff are trained about the importance of maintaining a persons privacy and dignity during their induction programme. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14, 15 Service users are encouraged to be self-determining and autonomous. The meals served at the home are wholesome and appealing served in pleasant surroundings. EVIDENCE: Service users records showed evidence that people were consulted about their preferences in respect of daily living and supported to fulfil their needs in this respect. For instance, people had expressed their preference in respect of daily routines, what they preferred to eat and where they wished to take their meals. Service users interviewed spoke of being supported by staff to conduct their life as they wished to. Personal living accommodation showed evidence of personal possessions and items brought in from their own homes or provided by family members. People were able to make decisions about where they wished to go and visitors they wished to receive in the home. The menus at the home were inspected and the cook in charge at the time of the inspection was interviewed. The home prepares two weekly menus and people are offered a choice of two main meal options and various choices at teatime. Each main meal comes with an option to have fresh vegetables and fresh fruit is available. The new owners CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 12 have changed their food suppliers and fresh meat and vegetables are now more readily available. Service users were happy with the range and quality of the food and any special dietary requirements were catered for. Records of cooked food temperatures were being maintained in accordance with food safety requirements and refrigerator temperatures were being maintained. Service user records showed that nutritional needs assessments were being carried out, and likes and dislikes were being taken into consideration. The home now has a system in place for recording individual diets and preferences on a daily basis and this is an improvement on previous practice. The dining area is nicely laid out and is a pleasant place to take meals. Another improvement the home could make is to consider separating the dining area from the lounge by providing partitioning. This would create a more private area and provide people with meaningful choices about where they wish to be seated. However, service users have the option to eat in their room if they wish to and there are three other quiet lounges and a conservatory to sit in if they wish. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has systems in place that enable people to make a complaint and for those complaints to be taken seriously. EVIDENCE: The home has a complaints procedure that is contained within the service users guide. The manager and the deputy are very approachable and service users spoken with felt that they could talk to them if they had a concern to raise. The home has received one complaint in the last 12 months, which was sent to the Commission. The complaint was referred to the home for investigation and evidence of such was provided. The complaint could not be substantiated, however the home responded with prompt action and introduced additional measures to ensure that good practice was maintained in respect of the complaint made. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The home provides accommodation and facilities of a high standard and has systems in place for ensuring it is kept clean and tidy. EVIDENCE: A tour of the premises was conducted and all areas were found to be clean, tidy and well-maintained. The home employs a team of domestics who work daily to maintain good standards of cleanliness and hygiene. Service users spoken with were happy with the cleanliness of their accommodation. The home in general is maintained to a good standard, the furnishing and fittings are of good quality and create a homely feel. There is a main lounge and dining room where activities take place. In addition, there are three other quiet lounges and a conservatory, which is the designated smoking area. The grounds are accessible and well-maintained, a number of the rooms lead out to a courtyard in the centre of the home where seating has been provided. The building is compliant with fire safety regulations and subject to regular inspections. Records relating to maintenance and renewal could not be produced on this occasion, however there are no concerns in this respect. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 15 CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Service users needs are being met, but staffing levels need to be reviewed to ensure that the correct balance is found between management hours and care hours. Recruitment practice has improved and now promotes the safety and welfare of service users. Staff are trained to fulfil the various elements of their role, however this cannot be fully demonstrated due to the lack of a formal training programme and a central training record. EVIDENCE: There is no evidence to suggest that service users needs are not being met as a result of the staffing levels at the home. However, recruiting new staff has been problematic and as such, staffing levels were low at the time of inspection. There are currently four staff on duty in the morning and three in the afternoon, on occasions the manager is providing hands-on care in order to ensure that staffing levels are adequate. The management hours should not be included in the care hours and the managers time should be devoted to ensuring the smooth running of the home. It is required that the management of the home review the staffing levels with a view to increasing them. See requirements. Staff files relating to three new care workers were inspected. Each contained an application form, evidence of identification, a completed CRB or POVA and CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 17 two written references. Each candidate is invited to attend a face to face interview and a record of the interview was seen. Those staff commencing employment prior to the completion of a full CRB check were being supervised at all times. The recruitment practice has improved and systems are in place to ensure that criminal records checks and POVA checks are completed prior to staff commencing. The organisation of files has been improved also making it easier to find locate information. The files could be further improved by including a file audit checklist that could be used to check that all documents are in place and this will add an extra safeguard to the system in place already. See recommendations. The new owners have introduced a training programme that is yet to be formalised. However, evidence of training was provided, all staff have been trained in dementia care and moving and handling updates have been provided. Adult protection training has been booked for staff to attend in October and a formal induction programme has been introduced, based on the TOPSS induction standards. Both the manager and the deputy manager have been attending management and leadership training to further enhance their skills and both are undertaking the NVQ 4. Improvements could be made by producing a formal training and staff development programme to demonstrate that the management are committed to providing regular training and have a budget to achieve this. See recommendations. In addition, the home would benefit from a central training record to demonstrate what training each individual has completed and when updates are required. See recommendations. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 38 The home can demonstrate that it is run and managed by a person that is fit to do so. Service users and staff benefit from clear leadership and management of the home underpinned by strong values and principles. The management cannot fully demonstrate that staff are adequately supervised due to the framework within which supervision takes place. The management cannot fully demonstrate that the health, safety and welfare of people living and working in the home is promoted due to the absence of some records in this respect. EVIDENCE: The home has a manager who was registered by the Commission in May 2005. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 19 The manager, Ann Morley has worked at Church Farm for a period of three years. She has been able to offer continuity of management of the home throughout the change in ownership, resulting in minimal disruption to staff and service users. The management approach is open and transparent, the manager is keen to involve staff and service users in the development of the service through regular consultation. The new owners have introduced a new supervision format that is very task focused and has an emphasis on training. Supervision should include, monitoring workloads and tasks, supporting staff through difficulties and promoting staff development, providing an opportunity to share concerns in respect of these matters. It is recommended that the supervision process is reviewed. See recommendations. A programme of supervision is being developed with a view to ensuring that all staff receive supervision at least 6 times a year. It was not possible on this occasion to assess the health and safety records held in the home as the records had been removed by the previous owner. A request for the records to be returned has been made and these will be inspected on the next inspection. The fire safety records were seen and showed that the home appeared to be compliant with fire safety regulations. A visitors book has been placed in the reception area and people are now asked to sign in and out of the home. This is an improvement and is required in respect of fire safety procedures. CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 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 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score N/A N/A N/A N/A N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 N/A 14 3 15 3 COMPLAINTS AND PROTECTION 3 N/A N/A N/A N/A N/A N/A 3 STAFFING Standard No Score 27 2 28 N/A 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 N/A N/A 3 3 N/A N/A N/A 3 N/A 3 CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 21 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 27 Regulation 18 Requirement The registered person must ensure that staffing levels are adequate to meet the needs of service users and ensure the smooth running of the home. The registered person must prepare, in consultation with the service user, a written plan of care for each service user. Timescale for action 30/10/05 2. 7 15 30/10/05 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. 5. Refer to Standard 9 29 30 30 36 Good Practice Recommendations It is recommended that the home introduces a system for monitoring the medication fridge temperature. It is recommended that the home introduces a file audit checklist for staff files. It is recommended that a staff training and development programme is produced. It is recommended that a central training record is maintained. It is recommended that the management undertake a review of the supervision process to make it more meaningful I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 22 CHURCH FARM Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR2 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI CHURCH FARM I55 S64306 Church Farm (an) V242607 060905 Stage 4.doc Version 1.40 Page 23 - 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!