Inspection on 10/05/05 for Fircroft Care Home

This inspection was carried out on 10th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fircroft Care Home 24/10/07

Fircroft Care Home 20/02/07

Fircroft Care Home 15/11/05

Fircroft Care Home 29/09/04

Fircroft Care Home 25/05/04

Fircroft Care Home 12/12/02

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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 Fircroft Care Home 114 Ladbroke Road Redhill Surrey RH1 1LB Lead Inspector Mr P Benthom Announced Inspection 10 May 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. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fircroft Care Home Address 114 Ladbroke Road, Redhill, Surrey. RH1 1LB 01737 773424 0208 669 6041 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) Fircroft Services Ltd Ms Miranda Telfer CRH (PC) 18 Category(ies) of Old age, not falling within any other category registration, with number (OP) 2. of places Dementia (DE) 18. Learning Disability (LD) 18. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be: ALL RESIDENTS TO BE OVER THE AGE OF 55 YEARS ON ADMISSION (UP TO TWO MAY BE 65 OR OVER (OP). The gender of those accommodated will be: MALE & FEMALE. Of the service users accommodated over the age of 65, up to two may fall within the category of OP. Date of last inspection 29 September 2004 Brief Description of the Service: Fircroft is a large detached house situated in the town of Redhill in Surrey. The home is owned by Fircroft Services Ltd and managed by Mrs M Telfer. The home is registered as a Care Home only, within the Service User category ‘ Learning Disability (LD) and Old Age (OP) The home is registered for a maximum of eighteen Service Users aged over fifty-five years. The service provides a homely and comfortable environment where Service Users are treated with dignity and respect. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is of the first inspection of the Home by the Commission for Social Care Inspection within the regulatory framework of the Care Standards Act 2000 for the year 2005/6. The Home’s performance was measured aginst the National Minimum Standards for Care Homes for Older People. A tour of the premises took place and care, training and Health and Safety records were inspected. The home had a comprehensive statement of purpose, which accurately depicted the services provided by the home. The service plans in place were comprehensive and are reviewed on a regular basis to ensure that they accurately depict service users’ needs. The home provided a high level of individualised support to service users. This was a commendable part of the home’s operation. The menus provided were appetising and well presented using fresh foods where possible. Links with service users friends and family were well developed and maintained by the operation of the home. Service users’ health needs were well met. The home has a positive and supportive relationship with the local surgery. All staff are trained in the administration of medication. The home has a thorough complaints procedure. There have been no complaints received either by the service or by the CSCI in relation to this service. The home is well maintained and furnished to high standard. It offers spacious and well-equipped accommodation to its service users. There is a commitment from the proprietors and manager to provide staff with continual training and development. What the service does well: Service Users were very complimentary about the care they received and considered the home met their needs well. All areas of the home are well maintained and some of the furniture and fittings have been replaced. The result is a bright spacious home with tasteful and well-chosen colour schemes and furnishings. Service Users have been involved totally in the choosing of the new décor and furniture. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 6 The service provides a lively and stimulating environment for its Service Users and all staff are totally committed to continually developing the service to meet the needs of the Service Users. Developmental training for all staff was seen to be an important part of the home’s operation and as such staff that work in the service are encouraged to develop their awareness of the needs of the Service Users. What has improved since the last inspection? 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. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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 Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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, 2,3, 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The Home has a Service User guide, which is informative and easy to read. Details of the practical provision the Home provides is included in the Statement of Purpose. All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. Service users visit the home prior to moving in and visits are made to potential service users at their homes or in hospital. Service users are admitted on an initial month’s trial period and this information is reproduced in the contracts and the statement of purpose. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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, 9, 9, 10 and 11 Health, personal and social care needs are effectively met in this home. EVIDENCE: Care plans were reported to be drawn up in consultation with service users and with their relatives/representatives. Care plans sampled were comprehensive and up to date; there was evidence that regular reviews took place. Encouragement and support was given to service users to promote independence within the limitation of each individual’s capabilities The manager stated that all service users were registered with the local primary care trust for the provision of general medical services. A policy and procedure for the administration of medication was sampled as part of the inspection process. The inspector evidenced that staff that ordered, received, administrated and recorded medication had received training. Two Service Users have recently died and there was found to be a robust policy of managing the issues associated with death and dying, in place. Remaining Service Users were kept informed of the process and afforded the opportunity to attend the funerals if they wished to. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 10 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) 12, 13, 14 and 15 The systems in place for full Service User participation indicated that Service Users views are both sought and acted upon. EVIDENCE: All Service Users have full and varied activity programmes. Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. Service users attend various day centre and adult education activities. A different variety of community-based activities are available. The activities programme was individualised in accordance with service users wishes and made appropriate use of college courses, community amenities and facilities. There are daily activity sessions held in the home and the deputy manager is responsible for the co-ordination of these activities. Service users had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Staff attempt to maintain links with Service Users’ families. Any visitors could be entertained either in the service user’s own room or in the garden. Friends are invited to visit. The home has maintained some good family links. There are no restrictions in terms of visiting times. There was evidence in the care Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 11 plans that service users are supported to be as independent as possible, and are free to make decisions where possible. The service users were free to move around the home consistent with individual risk assessments in place. Service Users spoken to by the inspector were all very positive about the support that they received from the care staff. All said they felt they were treated with respect. Service Users told the inspector about their routines of the day and it was clear that these were flexible and staff were responsive to the needs of individuals. Service Users’ care plans gave information about residents’ interests and social preferences and actions to support these were documented in their support plans. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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) The home has a satisfactory complaints system that is made available to all Service Users and staff. EVIDENCE: A large notice explaining the complaints procedure was displayed on the notice board in the reception area. Details of the complaints procedure are to be found in the Statement of Purpose and the Service Users welcome pack. The home has a No Smoking policy. Service Users and staff use an outside area for smoking. Staff have access to Surrey’s Multi-agency Vulnerable Adults Protection Procedures and staff are made aware of the detail of the Public Interest Disclosure Act of 1998. The manager is also a professional staff trainer and provides continual and updated training in all aspects of adult protection, to staff. All staff have had recent protection of vulnerable adult training updates as an integral part of their ongoing training. The manager has created a specific training package along with a video of how to recognise signs of abuse. The homes policy related directly to Standard 18 of the National Minimum Standards for Older People. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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 and 26 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The home had a spacious communal sitting room and a separate dining room which was also used for activities. All areas met the required standard and were tastefully decorated and furnished. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 14 Specialist bathing facilities and additional toilets were provided suitable to meet the needs of the service users and in close proximity to communal areas and bedrooms. All rooms were bright and adequately ventilated There were arrangements in place to control the temperature of the water to prevent legionella and scalding of service users. Standards of cleanliness in the home, were seen to be very high. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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, 29 and 30 The staff had a good understanding of Service Users need. This was evident from the positive relationships that have been formed between staff and Service Users. EVIDENCE: The Home has a policy whereby all gaps in the staff rota are met by existing staff. The Home has commenced a rolling programme of NVQ training for all staff. Nigh shifts are covered by two waking members of staff. All staff work night and day shifts in order to ensure that staff become familiar with Service Users needs throughout the 24-hour period and ensures a good continuity of care. Staffing levels comply with National Minimum Standards. All staff have completed induction and foundation training and there is a good training package for all staff leading to eventual NVQ training. The proprietor and the manager must be very highly commended for their commitment to training for all staff. The training programme follows the guidelines of the National Occupation Standards and each member of staff has an individual training and development plan. Training records were examined as part of the inspection process and were found to be up to date and detailed providing evidence of appropriate training being afforded to all staff at all levels. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 16 There is a very low staff turnover in this Home and there are appropriate training opportunities in place for all staff. and a commitment from the organisation to provide staff with a full and detailed training programme. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 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 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, 33, 34, 35, 36, 37 and 38 The manager is supported by staff in providing clear and consistent leadership in the home with all staff illustrating an awareness of their roles and responsibilities EVIDENCE: Information from service users and staff confirmed that the management style in the home was open and that registered the providers are approachable at all times. Meetings were held for both staff and service users; all were encouraged to contribute to the development of the home. During the course of the inspection the minutes of the last ‘residents and relatives’ meeting were read out to Service Users whilst they were having their lunch. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 18 The home has carried out a recent quality assurance audit and the completion of questionnaires has resulted in full and detailed information being provided to management and staff from Service Users. This has had great benefit upon the way the home delivers its service. It is to be very highly commended. Staff spoken to confirmed that they all received supervision regularly. Supervision notes were not seen as part of the inspection process as they were felt by the manager to be confidential. Records required for the protection of service users and sampled on the day of the inspection were well maintained, accurate, and up to date. The staff-training programme includes training in first aid, manual handling, infection control, fire safety, health and safety and basic food hygiene. Systems were in place to safeguard the health and safety and welfare of the service users. Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 4 4 4 4 3 4 4 4 Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There are to be no requirements from this inspection Timescale for action 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 Good Practice Recommendations There are to be no recommendations from this inspection Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.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 Fircroft Care Home H58 H09 s13641 Fircroft v216366 100505 Stage 4 ann.doc Version 1.30 Page 22 - 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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