Inspection on 05/07/07 for Church Farm Bungalow

This inspection was carried out on 5th July 2007.

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

The inspector 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 07/11/06

Church Farm Bungalow 17/11/05

Church Farm Bungalow 04/07/05

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

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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 Christine Bowman Unannounced Inspection 5th July 2007 12:00 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 Bungalow DS0000013603.V340264.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 Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 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 Dementia (1), Learning disability (12), Learning registration, with number disability over 65 years of age (7), Physical of places disability (7), Physical disability over 65 years of age (3), Sensory impairment (2) Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be admitted from the age of 50 years onwards only Date of last inspection 7th November 2006 Brief Description of the Service: Church Farm Bungalow is a care home in a cul de sac very close to St Peters Hospital. The home can accommodate twelve service users. The property is located in Chertsey, Surrey and is within walking distance of Ottershaw and a short drive from Woking town centre. Accommodation for service users is provided on the ground floor and has twelve single bedrooms. The home has a kitchen, a good size dining area, through lounge, two laundry rooms, bathing and toilet facilities and a quiet / activity room which is used by the staff as an office. The home has two vehicles both are able to accommodate service users in wheelchairs. The gardens are nicely laid out, secluded and private with ramps for wheelchair access. Private parking is available to the front of the property. The fees are £1,233.00 per week. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the Commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 12.00am and ending at 18.00pm and was undertaken by Ms Christine Bowman, regulation inspector. Mrs Catherine Burgess, the registered manager was available for most of the day to assist with the inspection process and a number of staff were spoken with including the shift leader responsible for the evening shift. The majority of the residents were leaving in the home’s minibuses to have lunch out at a favourite local restaurant, when the site visit commenced. One resident didn’t feel well enough to go and another resident was accompanied back to the home because she was feeling quite agitated and not enjoying the outing. Everyone else returned in the afternoon looking happy and recalling the various meals they had enjoyed. Some residents rested after lunch and others spent time in the large open plan sitting room watching the widescreen television and having their nails painted by a creative staff member. Later in the afternoon residents and staff socialised in the sitting room whilst tea was being prepared. Most of the residents had lived at the home for many years and had learning and physical disabilities and all required support with personal care tasks. One resident had dementia and another mental health needs and all were female. Some of the residents spoke freely and one enjoyed a joke, which was a little risqué, and others required communication aids. A tour of the premises was conducted and four resident’s rooms were viewed. Records and other documents were viewed including two resident’s care files, two staff recruitment files, a sample of health and safety certificates, staff training certificates, medication records, activity schedules and daily record sheets. Comment cards were sent for relatives and health and social care professionals to complete and some were also left for residents to complete. The inspector would like to thank the management, the staff and residents of Church Farm Bungalow for their assistance and hospitality on the day of the site visit and those who completed comment cards for their contribution to this report. What the service does well: The information produced for residents including the Service User Guide is in plain English and well illustrated with symbols and photographs to ensure the information is accessible to current and prospective residents. The Service User Guide is under review to include the information with respect to fees for services and extra charges. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 6 Residents are supported to maintain contact with their relatives and one relative of a resident commented, ‘we are a long way from our relative, but are in constant touch by telephone. We find everyone helpful with respect to her welfare and are informed of her many outings and treats. On many occasions she has been brought up North to see her family, to her delight and to ours. We thank all the staff for their care.’ The availability of two minibuses enables the residents to access the local community and enjoy a variety of interest. The complaints procedure was clear and included symbols and plain language to facilitate understanding. Key workers were allocated to residents and one-to one time planned to enable opportunities for residents to share any concerns they may have. Comments made by relatives with respect to what the service does well included, ‘It is very supportive to the residents and relatives,’ ‘It is very caring and provides a pleasant friendly atmosphere,’ and, ‘making the person happy in its friendly atmosphere, they are like one big, happy family.’ What has improved since the last inspection? What they could do better: Information with respect to standard charges, arrangements for charging and paying for additional services must be included in the reviewed Service User Guide (SUG) to inform current and prospective residents. A statement should Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 7 also be included about how the charges would be affected if a person were not self-funding. A staff training overview should be drawn up to confirm training dates and updates and to ensure access to mandatory training takes place in a timely manner. The staff personnel files would benefit from some reorganisation to facilitate the retrieval of information. A fire risk assessment and an emergency contingency plan must be held in the fire record folder to inform the staff and to safeguard the residents. Legionella testing must be carried out to protect the residents and the certificate must be available in the home to confirm this action has taken place. Resident’s relatives comments with respect to the improvement of the service included, ‘There is little need for improvement,’ ‘I think it is excellent,’ and, ‘I don’t think there is any need for improvement.’ 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 Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 8 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.V340264.R01.S.doc Version 5.2 Page 9 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): Standards 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is available in an accessible format to inform current and prospective residents about what the home has to offer and enable a decision to be made about its suitability for individual residents. Assessments are carried out prior to residents moving into the home to ensure their needs can be met there. The home does not provide for intermediate care. EVIDENCE: Residents had a copy of the Service User Guide, which gave detailed information about the home, in their bedrooms together with a licence agreement. The Service User Guide was well illustrated with symbols and photographs and written in plain English to facilitate understanding. This document was under review to include details of standard fees and extra charges to inform current and prospective residents. The records of two residents were inspected and care management assessments were included in one and a complete Wellmede assessment in the other. The manager stated that care management completed assessments for Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 10 all new residents and a decision was taken about the suitability of the home with respect to the prospective resident based on this information. The pre-admission assessments viewed included the likes and dislikes of the prospective residents, social needs, activities, occupation and links with community as well as health and personal care needs. The cultural and spiritual needs of the residents had also been recorded to inform carers and to ensure the home is equipped to meet the individual’s needs. Assessments sampled had been signed by residents to confirm acceptance. The manager stated that the home did not offer intermediate care placements. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents are well documented and healthcare professional are involved on a regular basis. Policies, procedures, staff training and safe storage ensure that medication is handled safely to protect the residents. Personal support is offered in such a way as to promote and protect service users privacy and dignity. EVIDENCE: Resident’s files sampled included ‘Life Plans’, which covered all areas of the individual’s health, personal and social care needs. The manager stated that person-centred planning was in the process of being introduced and some training had taken place to support this. Personal preferences with respect to eating and drinking, bathing, communication, hairdressing, chiropody, optical, hearing, mobility and other needs were recorded. Records were maintained of weight gain and loss and appropriate referrals made should the need arise, the manager stated. Residents with sensory needs had been supplied with the necessary aids to improve the quality of their lives and records kept of visits to healthcare professionals. All residents were registered with a GP and had Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 12 named key workers to maintain continuity. Annual health checks were undertaken to promote and maintain good health. The manager made a referral to the district nurse during the site visit and commented on the good service provided by the community health care professionals. The care plans sampled had regular monthly updates. Safe procedures were in place with respect to medication, which was mainly blister-packed from the local pharmacy. Medical Administration Records (MAR) viewed included photographs of the residents and had been completed appropriately. A list of the signatures of those staff trained in the administration of medication was available with the MAR sheets. Records were maintained of the receipt and disposal of medication. Medication was stored safely in a secured and locked metal medication cabinet. Protocols were in place for the administration of rectal diazepam signed by the resident’s General Practitioner. Risk assessments confirmed that no resident could safely take responsibility for their own medication. Observations of the staff interacting with the residents throughout the day confirmed they were treated with respect and a good rapport was noted. The staff knocked on the resident’s bedroom doors and waited for a reply before entering. A visiting healthcare professional commented that she has visited the home one day every eight weeks for over ten years and always found the residents to be happy, clean and well cared for. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A wide variety of social, cultural, and recreational experiences are available matching the individual lifestyle needs of the residents. Residents are supported to maintain contact with relatives and friends and to access the local community according to their wishes and needs. The residents are offered choice with respect to their diet and the menu is planned and well balanced. EVIDENCE: Weekly activity sheets were viewed in resident’s files and one resident’s individual plan included shopping, visiting the hairdresser, aromatherapy, listening to music, being entertained by ‘Us in a Bus’ (A theatrical group), bingo, meeting friends at a local public house, church, visit from family and watching the television. Next door to the home was a day activity centre called Geesemere, where most of the residents enjoyed sensory sessions in a sensory area known as Snoozelem. Reflexology was also accessed at this location. A visiting musical entertainer commented on the friendly and cheerful atmosphere in the home and that the staff supported and encouraged him in his efforts to serve the residents as a musical entertainer, making him feel accepted and valued on his visits. Residents spoken with stated they enjoyed going out for meals, visiting garden centres, playing bingo, choosing new clothes and taking holidays and day trips to the seaside. Holidays planned for Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 14 this year included four days in Minehead in September for three people staying at a hotel, which is a part of a new venture providing employment for people with learning disabilities, the manager stated. Two people were due to go on holiday to Hastings and a staff member stated that two staff take one resident to see her family in the North of England each year, staying in a hotel for two nights and arranging a family tea celebration for up to nine members of her family. Individual resident’s weekly meeting notes recorded residents’ choices and included comments by residents requesting a visit to the theatre. Records confirmed that following the request; residents had been taken to a Woking theatre to see a production about ‘Elvis’. Framed photographs in the corridors showed images of happy residents at the seaside, on holiday in Spain and the New Forest where Wellmede used to own a holiday home, partaking of celebratory meals, visiting zoos and entertainment centres. Having the use of two mini-buses facilitated the variety of involvement in the local community the residents were able to access, the manager stated. A number of pets were accommodated at the home including a cat, a budgerigar and several fish in a tank close to the entrance hall where a piano was also located. ‘The residents enjoy helping to care for them’, the manager stated, ‘and one resident likes to feed the wild birds in the garden.’ The relative of a resident commented, ‘we are a long way from our relative, but are in constant touch by telephone. We find everyone helpful with respect to her welfare and are informed of her many outings and treats. On many occasions she has been brought up North to see her family, to her delight and to ours. We thank all the staff for their care.’ On the day of the site visit the majority of residents when out to a restaurant for lunch as planned and recounted to the staff on duty in the afternoon what they had eaten. Accounts confirmed they had eaten well and enjoyed the trip out. This information had been recorded by the staff going off duty so awareness could be raised should a resident not have eaten well. A light tea was being prepared as the site visit ended and the tables were being laid in the dining section of the large open-plan living area. Some residents, who had been resting after the trip, were gathering in the living area chatting to the staff. The manager confirmed that the residents make their choices at menu planning meetings and that the diet offered is well balanced, with a good variety of freshly steamed vegetables. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 15 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): Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures and policies are in place to enable residents to make their views known and to ensure that residents are safeguarded from harm or abuse. The training of staff in the protection of vulnerable adults prepares them to be aware of situations, which could be potentially harmful or abusive to the residents. EVIDENCE: Systems were in place to enable residents to make a complaint. All residents had been supplied with a copy of the complaints procedure with the Service User Guide, the manager stated, and some of these were viewed in the resident’s bedrooms inspected. The procedure was clear and included symbols and plain language to facilitate understanding. Key workers were allocated to residents and one-to one time planned to enable opportunities for residents to share any concerns they may have. No complaints had been made to the commission for social care inspection and the home’s complaints and compliments folder could not be located. The shift leader stated that there had been no complaints that she was aware of, that residents were listened to, always taken seriously and action taken appropriately. Comment cards received from relatives confirmed that the complaints procedure had not been needed and healthcare professional’s comment cards confirmed that the home always responded appropriately if concerns had been raised about the care of residents. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 16 ‘The staff induction includes the Protection of Vulnerable Adults training during the first three days’, the manager stated, ‘and this training is regularly updated’. There was a copy of the local authority ‘Safeguarding Adults’ policy and procedure to inform the staff should a referral need to be made. There had been no referrals since the previous site visit. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 17 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): Standards 19,20,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit form a comfortable and homely environment, which is well maintained, hygienic and safe. EVIDENCE: The home had been purpose built some years ago and continued to meet the needs of the residents in a homely and comfortable way. Doorways and corridors were wide enough to accommodate wheelchairs and the entrance to the home and access into the garden were also negotiable. Handrails were provided in corridors to assist those with mobility needs. All the bedrooms were single, equipped with a sink and adequate furnishings, and provided sufficient space for wheelchair users. The bedrooms viewed were clean, bright, cheerful, personalised and arranged in two corridors leading from each end of the living area and enclosing the garden. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 18 The garden was pleasantly laid out, mainly to lawn, and accessible to wheelchair users. There was a covered swing-seat, a fountain, a bird table, a bar-b-cue and comfortable seating and sunshades for the enjoyment of the residents. No one was sitting outside on the day of the site visit because the weather was inclement, but a staff member stated that a number of the residents liked to sit in the garden when the weather was good. The shared accommodation consisted of a large open plan sitting and dining area, which was comfortably furnished and equipped with an entertainment centre consisting of a large widescreen television, DVD, video and compact disc player. Large windows looked out onto the garden and made the large room light and airy. Domestic lighting was provided and situated appropriately to assist individuals looking at magazines. There was a hatch from the dining room through to the kitchen through which the food was served. The kitchen was clean and tidy but in need of refurbishment. Some of the working surfaces were too low for staff to work at comfortably and some of the equipment was in need of updating. The manager stated that the refurbishment of the kitchen had been included in the development plan. The washing machines located in the laundry rooms, one on each side of the home, were equipped with a sluice programme. Hand washing facilities were available and paper towels and the staff were observed using the protective clothing provided by the home. The home employed dedicated part-time cleaning staff, but they not on duty on the day of the site visit, and consequently the standard of cleanliness in the entrance hall, where some packages had been unpacked, and corridor leading to the sitting room could have been improved upon and the manager stated that she would ask a member of staff to vacuum the area. Bedroom and bathroom facilities were clean and the home was free from unpleasant odours. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient, safely recruited and trained staff are available to support the residents at all times. EVIDENCE: Sufficient staff were available to residents throughout the day to enable planned activities to take place and the manager explained there was always a shift leader and a manager was always on call. The managers of the North Surrey Wellmede homes cover a week at a time ‘on call’ to support the staff in the homes covered by the area. Two waking night staff were on duty every night and there was a system in place, which allowed for a staff member sleeping in at one of the other homes as extra emergency cover for all the homes. The manager stated that 50 of the staff were either working towards a National Vocational Qualification or had already achieved one. The files of two staff, recruited since the previous site visit, were inspected. The manager stated that the recruitment procedure had been improved since the previous site visit. She does not allow staff to start work until their Criminal Record Bureau check has been cleared unless the North Surrey Primary Care Trust, through which the staff are employed, have sent proof that the staff member has been POVAFirst checked. Records confirmed that one staff member had waited for several months to start work and that a CRB check had been carried out and recorded. The record of the CRB check for the second staff member could not be located. The manager was immediately in Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 20 touch with the Human Resources Department and the number was placed on record in the home. The application forms completed on personnel files did not require a full employment history, but a reviewed application form supplied for employment with Surrey Primary Care Trust required all the necessary information including reasons for leaving, explanation of gaps in employment and an equal opportunities monitoring form. Personnel files included a photograph, two written references, a health statement, interview notes, terms and conditions of employment and contracts. The files would benefit from some reorganisation to facilitate the retrieval of information. The staff files sampled included individual development plans and certificates for training. Recent certificates included Moving and Handling, Fire Training, Food Hygiene, Safeguarding Adults, Health and Safety including COSHH, Autism Awareness, Dementia Care, Risk Assessment and National Vocational Qualification Certificates. A recently recruited staff member confirmed they had completed a thorough induction, attended mandatory training and had applied to complete a National Vocational Qualification. ‘Training planned included Equality and Diversity Training, Mental Capacity Training and extending Dementia Training to all staff,’ the manager stated. Although the staff had individual development folders and each one could be viewed separately, there was no staff training overview showing training updates and to confirm that training was updated in a timely manner. A copy of the training matrix should be sent to the commission for social care inspection to confirm that mandatory training is regularly updated. A visiting health professional, who has been attending to residents at the home for more than ten years, commented that she had always found the staff to be professional and caring. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well-qualified and experienced manager provides consistent leadership and good staff support. Systems are in place to ensure the home is run in the best interests of the residents and safe procedures protect their financial interests. Health and safety has improved but there remain some shortfalls, which need to be address to promote the health, safety and welfare of the residents. EVIDENCE: The manager was a registered nurse, had completed a National Vocational Qualification at level 4 in Management and had many years of experience of working with people with disabilities. There was good support from service managers and from managers of the other North Surrey Wellmede homes who meet regularly and provide on-call support for the area on a rota basis.The manager stated that a deputy had been recruited but could not commence employment until July. This would enable the manager to complete userChurch Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 22 friendly formats for the residents’ care plans, do a complete audit of the staff files, reorganise the office and complete actions from the quality audits carried out by the provider. A full audit conducted on behalf of Wellmede takes place annually, the manager stated, and all the managers of the North Surrey area homes carry out monthly visits on behalf of the provider on each other’s homes. Plans were in place to develop quality assurance questionnaires for residents, their relatives and other professionals to provide feedback to improve the service. Residents’ finances were well documented and those sampled had receipts to confirm transactions and balances were correct. The Control of Substances Hazardous to Health cupboards were secured to protect the residents. Health and Safety Certificates sampled were up to date including the portable appliance testing, the Gas and the Central heating certificates, but the Legionella test certificate was not available. The manager stated that she had requested the provider to book this service because Wellmede have contracts with providers for these services. A fire risk assessment and an emergency contingency plan were not available in the home on the day of the site visit. They should be available to inform the staff. The aid call system was in the process of being replaced. Documentation at the home confirmed the imminent installation of the new system and in the meantime the staff were making frequent checks when residents were in their bedrooms. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 23 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 X 3 X X X 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation Requirement Timescale for action 30/09/07 2. OP38 3. OP38 5(1) Information with respect to (bb)(bc)(b standard charges, arrangements d) for charging and paying for additional services must be included in the reviewed Service User Guide (SUG) to inform current and prospective residents. A statement should also be included about how the charges would be affected if a person were not self-funding. A copy of the reviewed SUG should be sent to the CSCI. 13 A fire risk assessment and an emergency contingency plan must be held in the fire record folder. (Previous requirement 22/12/06 not met) 17 The certificate to confirm Legionella testing had taken place to safeguard the residents, was not available. (Previous requirement 22/12/06 not met). 30/09/07 30/09/07 Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 25 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. Refer to Standard OP29 OP30 Good Practice Recommendations The staff files were in need of reorganisation. A staff training overview should be drawn up to confirm training dates and updates and to ensure access to mandatory training takes place in a timely manner. Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Church Farm Bungalow DS0000013603.V340264.R01.S.doc Version 5.2 Page 27 - 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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