Inspection on 17/11/05 for Church Farm Bungalow

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Church Farm Bungalow 05/07/07

Church Farm Bungalow 07/11/06

Church Farm Bungalow 04/07/05

Church Farm Bungalow 22/11/04

Church Farm Bungalow 22/06/04

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

CARE HOMES FOR OLDER PEOPLE Church Farm Bungalow Church Farm Bungalow Guildford Road Chertsey Surrey KT16 0PL Lead Inspector Helen Dickens Unannounced Inspection 17th November 2005 12:30 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 Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Church Farm Bungalow Address Church Farm Bungalow Guildford Road Chertsey Surrey KT16 0PL 01932 873082 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) Welmede Housing Association Ltd Mrs Caroline Burgess Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12), Physical disability (12), of places Physical disability over 65 years of age (12), Sensory impairment (12) Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users may be admitted from the age of 50 years onwards only The gender of those accommodated will be: FEMALE Date of last inspection 4th July 2005 Brief Description of the Service: Church Farm Bungalow is a care home providing personal care and accommodation for up to twelve female residents with a learning disability. The property is located in Chertsey, Surrey and within walking distance of Ottershaw; it is also only a short drive from Woking. All resident’s accommodation is on the ground floor and consists of twelve single bedrooms, each with its own hand-basin. There is a kitchen, dining area, and lounge. There is also a laundry, and bathing, toilet and washing facilities. The home has its own garden and car parking area. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Regulation Inspector. Leonora Richards, Deputy Manager, represented the establishment. A tour of the premises took place. All residents present on the day of the inspection were greeted by the inspector, and one spoken with in more depth. As the majority of residents have difficulty with verbal communication, other methods were used to ascertain their views such as observation and examination of care plans and the notes from resident’s meetings. The inspector also interviewed one member of staff in addition to the deputy manager. This was a positive inspection. The inspector would like to thank the residents and staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 6 Some of the requirements made at the last inspection have been dealt with including replacing the carpet in the lounge area. A jet washer had been purchased (though it now needs a spare part) and this should keep the patio area clean and safe underfoot. The broken wooden handrail has been replaced. Since the last inspection Church Farm Bungalow staff have worked hard to eliminate pressure sores, and there are currently none at this home. 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. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 the following standard(s): 2,3 and 5. Resident’s contracts still do not state which particular room or rooms they can occupy within the property. Resident’s had thorough pre-admission assessments on file, ensuring their health and social care needs had been properly identified. Prospective residents are given the opportunity to ‘test drive’ the home and assess it’s suitability. EVIDENCE: The resident’s files examined showed a good deal of background information on each person, this included assessments by the County Resettlement Team and care managers. Files showed care and social needs assessments, as well as detailing the assistance each resident required to perform activities for example, managing their finances. Special attention had been given to the ‘orientation’ of residents, prior to their discharge from hospital to Church Farm Bungalow. Copies of nursing and health assessments were on file including more recent appointments such as breast screening and cervical smears. The deputy manager outlined the process for accepting new residents, including trial visits and pre-admission meetings with professionals involved in the care and assessment of the prospective resident. Prospective residents Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 9 have the opportunity to assess the quality, facilities and suitability of the home. A recommendation was made at the previous inspection that the home considers the issue regarding which particular rooms residents can occupy, as set out in Standard 2.2. There is less security for residents if their contract does not state which particular bedroom they are entitled to occupy, and the home could, if they deemed it necessary, move the resident to another room. No evidence of any progress on this matter could be found on resident’s files. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. Resident’s care plans contain a good overview of each person’s health, personal and social care needs. However, further work needs to be done to meet this standard in full. The home has good systems in place for the administration of medication. EVIDENCE: Care plans had thoroughly looked at all aspects of residents needs and included, as well as their personal details and background, guidelines and assessments for managing pressure areas, moving and handling, dressing and personal care, and communication. Each plan had a regular weekly activities sheet and this was supplemented by the one-off activities and entertainments organised by the staff. Staff note on each plan which of these special events each resident attends. There was a good record of health interventions including some very good medical history summaries. The care plans are all ‘written’ in words and not in formats which residents would be able to understand; the home should review this in order to give residents greater involvement in their care planning. Also care plans do not appear to be reviewed on a monthly basis as per Standard 7.4 and this is an outstanding requirement from the previous inspection. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 11 The 2pm medicines administration was observed. The system used at this home safeguards residents. Advice is sought from a community pharmacist on the policies and practices within the home. The medicines are securely stored and the deputy manager said that all staff involved in administering medication have received training and an assessment, and their specimen signatures are at the front of the medicines administration record. Resident’s charts included their photograph and a note of any allergies. The home uses the NOMAD system and these are replaced and renewed by the local pharmacy. Previous advice from the community pharmacist regarding protocols for ‘as required’ medication had been acted upon. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. Resident’s social and recreational needs are catered for at Church Farm Bungalow. Contact with family and friends is encouraged and residents are supported to exercise some choice and control over their lives. EVIDENCE: All staff are involved in supporting resident’s with leisure and recreational activities, but one staff member takes the lead in organising communal activities, for example the visiting farm mentioned at the beginning of the report. Activities include going out for meals, trips to places of interest such as the adventure park and the seaside, theatre trips and short breaks away. Photographs are displayed within the home and serve as a reminder to residents and visitors of activities enjoyed throughout the year. Regular activities include bingo, visiting ‘Us in a bus’ and attending a day centre in Woking. An activity support worker comes in weekly and residents can do various artwork activities. Saturdays are usually for shopping and once a month the Welmede ‘Get Together Club’ meets and puts on a variety of activities including discos and barbecues in the summer, and is arranging carol singing as Christmas Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 13 approaches. Both regular and ad hoc activities are recorded on individual care plans. The photographs of recent pursuits showed that some relatives like to join in with communal activities and are encouraged to do so. Staff were knowledgeable about the family and friends of each resident and there were numerous examples of staff supporting and facilitating these relationships. One resident’s parent was in a care home and staff took the resident to visit on a regular basis; another resident had a sibling in a different part of the country, and again, staff took them to visit; yet another was supported to receive a weekly telephone call from their relative. There was evidence at this home that residents were supported to exercise choice and control over their lives. On the day of the inspection the deputy manager asked a resident if the inspector could look at their room and the resident refused – this was accepted immediately without further discussion and another resident approached. Resident’s rooms were very personalised with photographs and belongings; some even had all their own furniture. Residents were supported to manage their own money and this is discussed later in the report. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 There is some evidence that complaints would be taken seriously at this home but more needs to be done to meet this standard in full. EVIDENCE: A complaints procedure is available in the home and each resident has a copy in their own room. The deputy manager said staff go through this with residents from time to time. Staff have a number of ways in which they check if residents have concerns or worries including at resident’s meetings and one to one time with key workers. However, the complaints procedure in one room still had NCSC as the regulatory body and had not been up-dated as required at the previous inspection. In addition, the complaints procedure was all written in words and only one resident at this home can read the printed word. Some attempt has been made to do a pictorial representation of who a resident might complain to, and this should be extended to a simplified complaints procedure. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Church Farm Bungalow offers a clean, pleasant and hygienic environment for residents. EVIDENCE: On the day of the inspection the home was clean and pleasant, and free from any offensive odours. The laundry and utility areas were clean and tidy, as were the bathrooms and toilets. All basins had soap and paper towels available, and in some areas there was also alcohol rub where that had been assessed as appropriate. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Resident’s are protected by the home’s recruitment practices. EVIDENCE: This is a key standard which had to be assessed on this visit, but the deputy manager has little involvement in recruitment; the registered manager and the housing association usually handle this. However, the deputy manager was familiar with the main areas of recruitment policy and outlined to the inspector that two references were to be taken up, a criminal records bureau check needed to be done, and any gaps in employment history fully explored. There are currently no volunteers used at this home. Staff records are securely kept on the premises and only the manager and the service manager (who works next door) can access these. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35 and 38 There is some evidence that this home is run in the interests of residents but more information on quality assurance measures will be required before a judgement can be made. Resident’s financial interests are safeguarded by the home’s procedures. Systems for identifying health and safety concerns at this home are good though further progress needs to be made to speed up addressing these problems. EVIDENCE: The registered manager takes the lead on quality assurance at the home. As she was on leave at the time of the inspection, the home’s procedures were not readily available. However, the deputy manager was aware of some of the ways in which resident’s views were sought. This included residents meetings which are usually held monthly (though according to records there had been a gap for 3 months during the summer), and individually with key workers. A requirement will be made for the manager to send (to CSCI), evidence of the home’s quality assurance arrangements as outlined in Standard 33. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 18 Resident’s financial interests are well looked after by the home’s arrangements and systems. No residents look after their own money completely independently, but one is supported to go to the building society. Most residents either have families who look after their money for them, or have had solicitors appointed to look after their finances by the Court of Protection. Resident’s have small amounts of money, in their own ‘tin’, kept securely. This money is for aromatherapy, hairdressing etc. Written records of money in and out are kept, and one resident’s tin was checked and found to be correct. Money can be withdrawn from resident’s bank accounts with two designated staff signatures; careful records of monies in and out, and bank statements, are kept on file. Health and safety matters at the home are overseen by the registered manager; she has set up a file with all the information and certificates which may be required by a CSCI inspector, and this was helpful and saved time looking for individual items. Health and safety audits are carried out both by Welmede Housing Association and the local NHS. On the day of the inspection the hazardous substances cupboard was locked and attention to health and safety matters throughout the home was generally good. All the water outlets tested by the inspector were regulated to around 43C, and the broken handrail identified at the last inspection has been replaced. The prevention of legionella policy at this home is thorough but the certificate confirming the home was free from legionella could not be found and they were asked to forward this to CSCI. One outstanding issue remains from the last inspection. Though the jet washer was acquired to wash the patio, it has a part missing which has not yet been fitted and therefore does not work. The fire safety audit had highlighted a number of items needing attention and these had not all been dealt with; a requirement will be made in this respect. The home has recently submitted a number of Regulation37 notices on incidents affecting the well-being of residents and the inspector asked for more information. Details are recorded in the inspector’s notebook but no further health and safety matters were raised as a result of these discussions. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 19 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 X 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(2)(b) Requirement Resident’s care plans must be reviewed on a monthly basis as outlined in Standard 7.4. (Outstanding from 04.08.05). Resident’s care plans must be made available to them in a format they can understand. An action plan with timescales should be sent to CSCI within one month. The complaints procedure must be summarised into a format that is more accessible to residents. The current procedure must be up-dated to include the correct details for CSCI. The home must send a summary of quality assurance processes at Church Farm Bungalow, demonstrating compliance with Standard 33. a)An action plan detailing when the outstanding items from the last fire safety inspection will be completed must be sent to CSCI within one month. b)The home must confirm when the spare part for the jet washer DS0000013603.V267374.R01.S.doc Timescale for action 17/12/05 2. OP7 15(2)(a) 17/12/05 3. OP16 22(2) 22(7)(a) 01/01/06 4. OP33 24(1)(2) (3) 01/01/06 5. OP38 23(4) 17/12/05 Church Farm Bungalow Version 5.0 Page 21 has been fitted and, in the meantime, carry out a risk assessment for the patio. c)The legionella safety certificate should be located and sent to CSCI within one month. 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 OP2 Good Practice Recommendations Details about which room(s) each resident is entitled to occupy should be included in the contract between the resident and the home. Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Church Farm Bungalow DS0000013603.V267374.R01.S.doc Version 5.0 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. 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