Inspection on 21/03/05 for West Farm House

Care Home For Older PeopleWest Farm HouseCollingbourne Ducis Marlborough Wiltshire SN8 3DZUnannounced Inspection21st March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment West Farm House Address Collingbourne Ducis, Marlborough, Wiltshire, SN8 3DZ Email address Name of registered provider(s)/company (if applicable) Mrs Helen Burnett- Price Mr Barry Price Name of registered manager (if applicable) Mrs Helen Burnett-Price Type of registration Care Home No. of places registered (if applicable) 10 Tel No: 01264 850224 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (10) Registration number D010000393 Date first registered 2nd May 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 23rd July 2002 YES NO 18/08/04 If Yes refer to Part CWest Farm HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 321st March 2005 11:50 am Malcolm Kippax NA NA NAID Code071525Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNA Angela Dobson - Staff member Judy Washington - Staff memberWest Farm HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementWest Farm HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of West Farm House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.West Farm HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. West Farm House is registered to provide board, accommodation and personal care to up to ten older people. The home is situated in a quiet village location. A shop / post office and other village services are within walking distance of the home. West Farm House is a two storey, period property in which the original features have been carefully maintained or restored. The style of decoration and furnishing of the accommodation is in keeping with the character of the property. Some adaptations and changes to the facilities have been made to meet the needs of older people. There is a large well-kept garden with a lawn and seating areas. The communal areas of the home include a lounge, a dining room and a sun lounge extension. The service users individual accommodation is on the ground and first floors. A passenger lift is available. At the time of the inspection each service user had a single room, although shared accommodation may also be available. All rooms have an en-suite facility. The owners, Mrs Burnett-Price and Mr Price, are closely involved in the day to day running of the home. Mrs Burnett-Price overviews the care of the service users and supervises a permanent staff team.West Farm HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)West Farm HousePage 6 Two staff members were working at the time and assisted during the inspection. The inspector was informed of service users who had moved in since the last inspection. Most of the inspectors time was spent talking with service users in their rooms. Staff members said that Mrs Burnett-Price and Mr Price had left the home for a hospital appointment shortly before the inspector arrived. The inspector was told that many of the homes records could not be accessed in their absence; this included the service users assessment and care plan records. As a consequence, staff members had little written information available to them and many of the requirements and recommendations identified at the previous inspection could not be followed up. The inspector will be making a further visit to the home in connection with these. The standards that were not looked at on this occasion had been assessed during the previous inspection of the home. Choice of Home (Standards 1-5) Two standards were assessed. One was met and one was not met A new service user said that she had been able to visit West Farm House before moving in. Another service user said that her family had made all the arrangements and she had not actually seen the home or the room she now occupied. However, she was happy that the decisions about the move had been made on her behalf. Some service users were familiar with the local area and had known the home before moving in. One service user said that West Farm House was chosen because it was conveniently located for members of her family. A new service user showed the inspector a copy of the Statement of Purpose and the guide that she had received when moving into the home. As reported at the previous inspection, these documents need to be updated and to include all the required information. This will give a fuller description of the facilities and type of service that the home provides. Health and Personal Care (Standards 7-11) One standard was assessed and met Each service user has his or her single room in which personal care can take place in private. The rooms have en-suite facilities. Service users were mainly spending time in their own rooms during the inspection. The service users met with said that they have good relationships with staff and are spoken to in a respectful and friendly manner. Service users were appreciative of the support that they receive. One service user said that she managed some of her own medication. Daily Life and Social Activities Standards (12-15) One standard was assessed and met One service user went out with a relative during the inspection. Visitors are asked to sign a book upon arrival and when leaving the home. Some service users spoke about their family connections and receive regular visits from family members. West Farm House is in a quiet village location. Service users, with varying degrees of support are able to go to a `convenience store that is off the main road. Other village West Farm House Page 7 amenities are nearby. The position of the home is appreciated by a number of service users who have well established social contacts in the area. Lunch was served to service users shortly after 1pm. Meals are the main time that service users come together. There is a large table in the dining room that seats most people, with two smaller tables also available. Comments made about the meals were very positive. Complaints and Protection (Standards 16-18) These standards were not assessed A `Complaints, Accidents and Missing Persons file was kept in the kitchen. The file included copies of some complaint related correspondence although none of this was recent and the last seen was dated 1999. A Police Officer attached to the Vulnerable Persons Unit has visited the home since the last inspection. This was a session with staff as part of training to increase knowledge and awareness of abuse and adult protection issues. Environment (Standards 19-26) One standard was assessed and not met The home retains many of its original, period features, although some adaptations have been made to the property to meet the needs of older people. It has been reported following previous inspections that the need for a portable hoist should be kept under review as part of a more comprehensive assessment of the service users moving and handling needs. The service users met with had brought a range of furniture and personal possessions with them into the home and this gives the rooms a homely and individual appearance. Radiators in the sun lounge were well covered although a requirement was identified at the last inspection concerning the uncovered radiators, which may present a risk to service users who are unsupervised in their rooms The inspector has since received confirmation from Mrs Burnett-Price that a radiator cover has been fitted in one bedroom and that covers were being ordered for the other rooms. The inspector saw a cover that had recently been fitted to the radiator in one service users room, although radiators in other locations had not yet had covers fitted. The inspector has written to Mrs Burnett-Price and Mr Price about this following the inspection. The rooms seen during the inspection looked clean and there were no unpleasant odours. Staffing (Standards 27-30) These standards were not assessed Two staff members were working at the time of the inspection. A staff roster was not available. One staff member said that she was working until 6pm, when another person would come on duty. The other staff member said that se would be working until Mrs Burnett-Price and Mr Price returned. Service users described staff as being helpful and friendly. Since the last inspection, there have been discussions about the lack of waking night staff cover in the home and the need to ensure that service users are safe and that their care needs are appropriately met throughout the night. In response to this, Mrs Burnett-Price has West Farm House Page 8 produced a policy on the provision of additional facilities, support or supervision for service users during the night. Management and Administration (Standards 31-38) One standard was assessed and not met Mrs Burnett-Price has managed West Farm House for several years and is aware of the need under National Minimum Standards, to have a qualification, at level 4 NVQ, in management and care or equivalent. Mrs Burnett-Price had joined staff in taking NVQ at level 2 at the time of the last inspection and was recommended to take advice about the best route to follow in order to achieve the appropriate qualifications as registered manager. As previously reported, the homes main records were not available at the time of the inspection. For reasons of confidentiality, some records, e.g. those relating to staff, may need to be kept separately. However, the other records, including those relating to the service users and health & safety need to be readily available.West Farm HousePage 9 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4, 5 OP1 The Registered Person must ensure that the Statement of Purpose is further developed to include matters such as room sizes and the staffing arrangements, during the day and during the night. The contents of the Statement of Purpose and the service users guide must be kept under review and updated accordingly. 2 18(1)(a) OP4 The Registered Person must ensure that assessments are undertaken of the current service users needs during the night and copies of these sent to the Commission. When the assessments have been completed, each service users plan of care should set out the action that needs to be taken to ensure that needs are being met. (Copies of the service users `needs at night assessments were sent to the Commission in October 2004) 3 15 OP7 The Registered Person must ensure that service user plans contain greater detail, including directives from GPs, intervention from other health care professionals and equipment used. The Registered Person must devise a programme for the refurbishment of the laundry and submit these to the Commission BY 31/10/04 BY 31/10/04 BY 31/10/04513(3)OP26BY 31/10/04West Farm HousePage 10 617(2)OP29The Registered Person must ensure that copies of documentation re: proof of identity are obtained and included as part of the staff employment records The Registered Person must ensure that: · Entries in the service users records are initialled by the person who has made the entry. The accident report forms include the time of day when the accident occurred.FROM 27/08/04817OP37FROM 27/08/04· 9 23(4) OP38The Registered Person must ensure that the fire log book includes: · · The names of staff who have participated in fire drills The dates on which staff members received instructionFROM 27/08/04A records of monthly check of fire fighting equipment Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 3 4 OP1 OP4 OP7 OP8 The service users guide should include a copy of the most recent inspection report and service users views of the home The manual handling assessments should include greater detail and guidance for staff That the care plan format is changed to give a clearer record of the current information That health and care related matters are more clearly identified in the service users report books That tasks and interventions identified in the assessments are included in the care plans, with a record kept of the checks that are made 5 6 OP15 OP26 That service users are informed prior to the meal of what is to be served A record should be kept of checks on the water system for Legionella Page 11West Farm House 7OP29The application form for employment should be amended to ensure that applicants are required to give their current or most recent employer as a referee That a matrix is produced as a record of staff training Staff members should confirm by signing that they have read and understood the homes policies and procedures8 9OP30 OP36CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)West Farm HousePage 12 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4(1)(c) OP1 Schedule 1 The registered person must ensure that the homes Statement of Purpose contains all the required information and that a copy is supplied to the Commission The registered person must ensure that: · 2 13(4)(a) OP25 · Radiators do not present a hazard to service users The Commission receives confirmation of the fitting of radiator covers BY 10/05/05FROM 22/03/05 BY 10/05/05 FROM 22/03/05317(3)OP37The registered person must ensure that the homes records are available for inspectionRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard *West Farm HousePage 13 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.West Farm HousePage 14 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES NO NO NO NO NO NO YES NO YES NO NO NO NO YES NO NO 6 0 0 NA NO YES YES X X 21/03/05 11:50 2.0West Farm HousePage 15 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.West Farm HousePage 16 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceYES HAIRDRESSING, CHIROPODY, TOILETRIES, MAGAZINES / PAPERS AND TRANSPORT 1 Standard met?One service user said that West Farm House was chosen because it was conveniently located for members of her family. Another service user had been familiar with the local area before moving in. A new service user showed the inspector a copy of the Statement of Purpose and the guide that she had received when moving into the home. As reported at the previous inspection, these documents need to be updated and to include further information and the required items. This will then give a fuller description of the facilities and type of service that the home provides.West Farm HousePage 17 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? Assessment records were not available for inspection.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Assessment records were not available for inspection.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The inspector met with a new service user who said that she had been able to visit West Farm House before moving in. Another service user said that her family had made all the arrangements and she had not actually seen the home or the room she now occupied. However, she was happy that the decisions about the move had been made on her behalf.West Farm HousePage 18 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Intermediate care is not provided at West Farm House and there are no facilities for this in the home.West Farm HousePage 19 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence Standard not assessed on this occasion. X X Standard met? 0West Farm HousePage 20 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? Standard not assessed on this occasion.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Service users were mainly spending time in their own rooms during the inspection. Each service user has a single room in which personal care could take place in private. The rooms have en-suite facilities The service users met with said that they have good relationships with staff and are spoken to in a respectful and friendly manner. Service users were appreciative of the support that they receive. One service user met with said that she managed some of her own medication.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 21 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? One service user went out with a relative during the inspection. Visitors are asked to sign a book upon arrival and when leaving the home. Some service users spoke about their family connections and receive regular visits from family members. West Farm House is in a quiet village location. Service users, with varying degrees of support are able to go to a `convenience store that is off the main road. Other village amenities are nearby. The position of the home is appreciated by a number of service users who have well established social contacts in the area.West Farm HousePage 22 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence The details of this standard not assessed on this occasion. A `Complaints, Accidents and Missing Persons file was kept in the homes kitchen and available during the inspection. The file included copies of some complaint related correspondence, although none of this was recent and the last seen was dated 1999. X X X X X X X 0Standard met?West Farm HousePage 24 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence The details of this standard not assessed on this occasion. A Police Officer attached to the Vulnerable Persons Unit has visited the home since the last inspection. This was a session with staff as part of training to increase knowledge and awareness of abuse and adult protection issues. Standard met? NO X 0West Farm HousePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 26 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. It has been reported following previous inspections that the need for a portable hoist should be kept under review as part of a more comprehensive assessment of the service users moving and handling needs. An example of a suitable format for the recording of moving and handling assessments was sent to Mrs Burnett-Price after the last inspection. The inspector was not able to see how these, or other forms were being used.West Farm HousePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence Standard not assessed on this occasion. NO NO YES X X X X Standard met? 0 X XX X X XWest Farm HousePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? The details of this standard not assessed on this occasion. The service users met with had brought a range of furniture and personal possessions with them into the home and this gave the rooms a homely and individual appearance. At the time of the last inspection a bolt was fitted on the outside of one service users bedroom door. The use of this bolt has been a matter of serious concern to the Commission and the subject of discussion since the last inspection. The bolt in question has been removed and the occupancy of this particular room has changed.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? Rooms are centrally heated with adjustable radiators. There was discussion at the last inspection about the risk to service users of hot surfaces. Radiators in the sun lounge were well covered although a requirement was identified concerning uncovered radiators, which may present a risk to service users who are unsupervised in their rooms. The inspector has since received confirmation from Mrs Burnett-Price that a radiator cover has been fitted in one bedroom and that covers were being ordered for the other rooms. The inspector saw a cover that had recently been fitted to the radiator in one service users room, although radiators in other locations had not yet had covers fitted. The inspector has written to Mrs Burnett-Price and Mr Price about this since the inspection. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? The rooms seen during the inspection were clean with no unpleasant odours. The laundry / boiler room is to be refurbished in 2005 although the inspector has not yet received detailed plans about this.West Farm HousePage 29 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 0West Farm HousePage 30 The details of this standard were not assessed on this occasion. Two staff members were working at the time of the inspection. A staff roster was not available. One staff member said that she was working until 6pm, when another person would come on duty. The other staff member said that she was working until Mrs BurnettPrice and Mr Price returned. Service users described staff as being helpful and friendly. Since the last inspection, there have been discussions about the lack of waking night staff cover in the home and the need to ensure that service users are safe and that their care needs are appropriately met throughout the night. In response to this, Mrs Burnett-Price has produced a policy on the provision of additional facilities, support or supervision for service users during the night. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Standard not assessed on this occasion. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 31 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 32 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Mrs Burnett-Price has managed West Farm House for several years and is aware of the need under National Minimum Standards to have a qualification, at NVQ level 4, in management and care or equivalent. Mrs Burnett-Price had joined staff in taking NVQ at level 2 at the time of the last inspection and was recommended to take advice about the best route to follow in order to achieve the appropriate qualifications as registered manager. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 33 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard not assessed on this occasion. Standard met? 0 X X XWest Farm HousePage 34 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 1 Key findings/Evidence Standard met? Staff members had access to some records that they may need to complete when on duty, including medication and accident report forms. However, the homes main records were not available at the time of the inspection. For reasons of confidentiality, some records, e.g. those relating to staff, may need to be kept separately. Other records, including those relating to service users and health & safety, need to be readily available.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.West Farm HousePage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateMalcolm KippaxSignature Signature SignatureWest Farm HousePage 36 Public reports It should be noted that all CSCI inspection reports are public documents.West Farm HousePage 37 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 21 March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWest Farm HousePage 38 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan Other: The availability of records will be discussed further with the manager (Requirement 3)YESNONOWest Farm HousePage 39 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Mrs H. Burnett-Price of West Farm House, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Mrs H. Burnett-Price of West Farm House, am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.West Farm HousePage 40 West Farm House / 21st March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000028653.V212302.R01© This report may only be used in its entirety. 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