Inspection on 04/07/05 for Church Farm Bungalow

This inspection was carried out on 4th July 2005.

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

The inspector 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 Bungalow 05/07/07

Church Farm Bungalow 07/11/06

Church Farm Bungalow 17/11/05

Church Farm Bungalow 22/11/04

Church Farm Bungalow 22/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Church Farm Bungalow Guildford Road Chertsey Surrey KT16 0PL Lead Inspector Mr Deananand Ramdas Announced 04 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Church Farm Bungalow Address Guildford Road Chertsey Surrey KT16 0PL 01932 873082 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) Welmede Housing Association Ltd Mrs Caroline Burgess Care Home 12 Category(ies) of LD - Learning Disability (12) registration, with number of places LD(E) - Learning Disability over 65 (12) PD - Physical Disability (12) PD(E) - Physical Disability (12) SI - Sensory Impairment (12) Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be admitted form the age of 50 years onwards only 2. The gender of those accomodated will be :FEMALE Date of last inspection 22nd November 2004 Brief Description of the Service: Church Farm Bungalow is a care home providing personal care only. It can accommodate twelve service users. The property is located in Chertsey, Surrey and is within walking distance of Ottershaw and a short drive away from Woking. Accommodation for service users is provided on the ground floor that has twelve single bedrooms. The home has a kitchen, a dining area, a lounge area, laundry facilities, bathing and washing facilities, and its own transport. The house vehicle has been adapted so that people in wheelchairs can use it. The home has gardens that is private, secure and has wheelchair access. Private parking is available to the front of the property. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of 7 hours. A full tour of the premises took place and staff and service users were spoken to. Care records and other documents were inspected. The inspector would like to thank staff and service users for their contribution during the inspection. Feedback forms, comment cards and business cards were left at the home. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure service users Life Plans are regularly reviewed and updated so that any changes in needs are identified and met by staff. Where risks are identified staff must ensure care plans are in place to manage the risk so as to maintain service users safety. Policies and procedures must be updated and amended to ensure staff and service users have available up to date information on which to make decisions. The premises must be made better by replacing the carpet in the lounge and dining areas to make it nice and homely for service users. The patio areas in the garden must be cleaned and maintained to ensure safe wheelchair access for service users. Wooden handrails in the garden must be Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 6 repaired to ensure staff and service users are not exposed to unnecessary risks. 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 v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 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 Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 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) 1,2. The homes Statement of Purpose and Service User Guide are excellent providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. Service users were issued with contracts that protected their rights. However, contracts did not specify the room to be occupied. EVIDENCE: The home had a Statement of Purpose and Service User Guide. They had information about the home. The Statement of Purpose contained information about the accommodation, philosophy of care, community participation, dignity and respect, choice, services provided, daily activities and staffing. The Service User Guide was written in plain English and the information was well presented. Pictures and symbols were used to explain the details of the services provided. It described the kind of service you would receive at the home including who would provide this service and how staff would communicate with you to help you understand. Service User Guides were kept in their bedrooms. The home had license agreements that were kept in service user’s Life Plans. These were issued when service users moved to the home and were signed by a Director of the Housing Association. The inspector noted license agreements did not specify the rooms to be occupied. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 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) 7,8,10 The health needs of service users are met with evidence of other health care professionals being involved on a regular basis. However, the review of care plans must be undertaken regularly to ensure they are appropriate to the needs of service users. Personal support is offered in such a way as to promote and protect service users privacy and dignity. EVIDENCE: The home had Life Plans. The inspector sampled the plans that contained personal information, assessments, priority needs, goal plans and progress reports. The Life Plans covered areas of health, personal and social care needs. One service user plan had written information on health care needs. It was recorded the service user saw GP on 1.7.05, the dentist on 20.4.05, the chiropodist on 17.6.05 and the district nurse regularly. Service users were registered with a GP and had named key workers. Nursing support was provided from Chertsey Health Centre. The manager stated she made referrals to the Continence Advisor, the Speech and Language Therapist and the Wheelchair Service at St. Peters Hospital. The inspector noted one service user had been referred for a new seat cushion to be fitted to her wheelchair and another was assessed by a speech therapist on the 11.1.05. During a meeting staff stated the home provided an excellent standard of care. One service user remarked staff do all my care. There was evidence to indicate Life Plans were not regularly reviewed and the inspector noted the home failed to notify the Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 10 Commission of a service user who had a Grade 4 pressure sore. This was discussed with the manager. Staff treated service users with dignity and respect. They were observed to address service users by their preferred names. The manager knocked on service users bedroom doors and sought permission before entering their bedrooms. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 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) 15 The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home employed a cook who had been in post for eight years and is familiar with the likes and dislikes of service users. The cook stated the menu is planned two weeks in advance and staff and service users are consulted. On the day of the inspection the dining tables were laid with knife, fork, spoons and tablemats with jugs of orange drinks available. The inspector noted service users had a light lunch of vegetable burgers with spaghetti that was nicely presented. Mealtime was relaxed and unhurried and staff interacted appropriately with service users. The manager was observed sitting next to a service user feeding her and talking to her during lunch. The deputy manager asked service users whether they enjoyed their meals. The inspector sampled the menu plans and noted meals were healthy, well balanced, varied and offered choice. It was recorded in the daily handover notes on 26.6.05 that two service users had helped with lunch that day. On the day of the inspection four service users went out to lunch at the local Harvester supported by staff. One service user stated the food is very nice and she liked chicken and fish and chips. The inspector noted this was on the weekly menu. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 12 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) 16,18 The complaints process at the home is satisfactory with complaints information available to service users. However, the complaints policy must be updated and amended. Staff have good knowledge and understanding of Adult Protection issues which protects service users from abuse. EVIDENCE: The home had a complaint policy that was issued in 1998. It was due for review in Jan 2000. The manager stated the policy had been reviewed but was unable to produce an up to date copy. The whistle blowing policy was up to date and is due for review in 2006. The inspector noted staff dated and signed the policy. The Housing Association complaint procedure for care homes was revised in 2002 and had attached a complaint notification form. Minor amendments are to be made to reflect the change from NCSC to CSCI. The home had the Surrey multi-agency protection of vulnerable adults policy that was up to date. The manager stated the home had received no complaints. The home did not have a complaints book. The inspector noted the complaint procedure for care homes was available in service users bedrooms. During a meeting, staff stated they were aware of the complaint and whistle blowing policy. The inspector found evidence in staff files that they had undertaken training in vulnerable adult procedures. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 13 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) 19,20,21,22,23,24,25,26 The standard of the environment within this home is satisfactory providing service users with a homely place to live. However, the carpets in the lounge and dining areas must be replaced to make it nice and attractive for service users and the patio area in the garden must be cleaned to ensure service users in wheelchairs can access the garden safely. EVIDENCE: The property was well maintained. The gardens were private, secure and had wheel chair access. A wooden handrail was in need of repair and the patio area needed cleaning as it presented a slip hazard to service users and staff. The standard of décor throughout the home was satisfactory but some areas will be in need of refurbishment. This was discussed with the manager who agreed to do a refurbishment plan for the home. On the day of the inspection the home was found to be clean, well ventilated and free of mal odour. Bathrooms and toilets were clean and hygienic. Bedrooms were well presented and personalised with family photographs, books, cards, radio, television, flowers and ornaments. One service user remarked she liked her bedroom. The manager stated she had written to the Housing Association to replace the carpets in the lounge and dining areas. The inspector noted the carpets were Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 14 marked and stained and action has been required in respect of this matter. The home was fitted with grab rails, assisted baths and toilets, and had hoists to help service users maintain their independence. The home had an aid call system. Staff were observed to follow infection control measures with frequent hand washing using anti-bacterial gel. Gloves and aprons were also available. The manager stated the home had no cases of MRSA. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 15 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) 27,28,30 The staffing at the home is adequate ensuring service users needs are met. Staff training is satisfactory ensuring service users are appropriately supported. The arrangements for the induction of staff are good with staff demonstrating a clear understanding of their roles. However, the home must appoint a named staff to supervise a new employee for the duration of their induction. EVIDENCE: On the day of the inspection staffing levels were adequate. On duty were the manager, deputy manager, five support workers, a cook and a domestic. The inspector checked the duty rota that reflected the numbers of staff on duty. The manager stated additional staff would be booked on duty to support service users doing activities. During a meeting staff stated a day trip to Worthing was planned for all service users and the manager had booked extra staff for the trip. There is an ongoing NVQ training programme. The inspector noted three staff had first level nursing qualifications and five staff had completed the NVQ care award. The manager remarked the use of agency staff had reduced due to permanent staff returning from sick leave. The inspector sampled the staff file of one employee who joined the home six months ago and noted she had completed the TOPSS induction programme that was dated and signed 5.5.05. The home had a policy on staff induction that was issued in 2004. The inspector noted the home did not appoint a named staff to supervise a new employee for the duration of their induction. This was discussed with the manager. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 16 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. The manager is supported well by senior staff in providing clear leadership throughout the home. The management style at the home ensures openness that benefits service users. EVIDENCE: The manager is a Registered General Nurse and has the Registered Managers Award. She is experienced and has been in post for over seven years. The manager described her management style as being ‘democratic’. She stated she consults with staff. During a meeting staff stated the manager was considerate, approachable and always took appropriate actions. They remarked the manager showed respect and made them feel valued. The inspector noted the home had regular team meetings and staff stated they had regular supervision where they were allowed to express their views about management. The minutes of staff meetings were sampled. It was noted the manager discussed and introduced a policy on sickness reporting dated the 17.6.05 providing clear leadership to staff team. Service users were also consulted in particular about the menu and activities. Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 17 Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 18 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 3 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 x x x x x x Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 19 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. 2. Standard 20 19 Regulation 23(2b&d) 23(2o) Requirement The registered person must ensure the carpet in the dining and lounge area is replaced. The registered person must ensure the paved area providing wheelchair access to the back garden is cleaned and well maintained. The broken wooden hand rail must be repaired. The registered person must ensure Life Plans are regularly reviewed and updated at least monthly. Where a risk is identified the registered person must ensure there is a care plan describing how that risk would be managed by staff. The registered person must ensure that all notifiable incidents including Grade 4 pressure sores must be reported to the Commission without delay. The registered person must ensure an up to date copy of the complaint policy is available at the home and where appropriate references made to NCSC is amended to CSCI. The registered person must ensure that service users Timescale for action 10.10.05 04.08.05 3. 7 15(2b) 14(2a) 04.08.05 4. 38 37(1b) 10.07.05 5. 1 22(6a) 04.08.05 6. 2 5(1b&c) 04.08.05 Page 20 Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 7. 36 18(2bi) contracts specify the bedroom to be occupied. The registered person must ensure that a named staff is appointed to supervise a new employee for the duration of their induction period. 04.08.05 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. Refer to Standard 33 Good Practice Recommendations The registered person should ensure a development plan is available at the home. The plan should prioritise areas of refurbishment with timescales. It is recommended that a copy be sent to CSCI. The registered person should ensure a copy of the Care Home Regulations 2001 (Miscellaneous Amendments) is available at the home. 2. 30 Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Church Farm Bungalow v226381 h58_s13603_church farm bunglaow_v226381_040705_stage4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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