Inspection on 19/01/06 for 1 Upfield

This inspection was carried out on 19th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Upfield 09/10/07

1 Upfield 19/12/06

1 Upfield 21/11/05

1 Upfield 26/01/05

1 Upfield 27/07/04

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Insight - Eastchurch

Southfields

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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 HOME ADULTS 18-65 Upfield (1) 1 Upfield Horley Surrey RH6 7JY Lead Inspector Deavanand Ramdas Unannounced Inspection 19th January 2006 10:00 Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 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 Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Upfield (1) Address 1 Upfield Horley Surrey RH6 7JY 01293 782396 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) Gresham Care Mrs Susan Mary Mallett Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 18 -45 YEARS 26th January 2005 Date of last inspection Brief Description of the Service: Upfield is a registered care home for six people with a learning disability which is located in Horley, Surrey. The property is detached and accommodation is on two floors accessed by stairs. The home has six single bedrooms, a lounge, kitchen, dining area, bathrooms, toilets, showers and office. Public amenities are easily accessible and the home is within walking distance of the local town centre with banks, post office, restaurants, pubs, and various shops. The home has a large garden which is well maintained and secure and private parking is available. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of four hours. A partial tour of the premises took place, staff and service users were spoken to, and care records and documents were inspected. Some service users living at the home have communication difficulties and judgements about them were made based on observations of their mood, behaviour and information given by staff. The inspector would like to thank the manager, staff and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? The home has met the requirements detailed in the previous inspection report which has resulted in improvements in care practice and the environment. The provider had invested in under floor heating installed in a service user’s bedroom to minimise risks and promote the safety of the service user which is good practice. The home is committed to staff training and development and the provider has produced a training and development plan and a service development plan dated 2006 which has dedicated budget for staff training. The standard of décor in the home has improved making it nice and attractive for service users. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 6 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. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The homes statement of purpose and service user guide are good providing details of the services the home offers enabling an informed choice to be made about admission to the home. EVIDENCE: The home had a statement of purpose and service user guide and the information it contained was in a widget format which used symbols to make the information understandable to service users. The service user guide was well presented, written in plain English and copies were available to service users. The statement of purpose was reviewed and updated by the manager and described the aims, objectives and philosophy of the home Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8&10. Decision making by service users is supported in the home and staff respect service users’ right to make decisions. The arrangements at the home ensure service users are consulted and participate in the day to day running of the home. The policy on confidentiality is adequate ensuring information held on service users is appropriately handled. EVIDENCE: The manager stated service users were supported to make decisions about their daily lives which were reflected in the person centred plans. The inspector noted one service user kept a record of his personal monies and staff referred two service users to the advocacy services to enable them to participate in independent advocacy. The home had a policy on activities and lifestyle and the manager stated the home had regular meetings with service users which offered the opportunity to participate in the day to day running of the home. The home provided service users with understandable and up to date information on its policies and procedures and the complaint policy was in a widget format. The home had a policy on confidentiality and service users individual records were accurate, secure and confidentially stored in the manager’s office. During Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 10 discussions, a member of staff stated information would only be shared with other agencies on a need to know basis. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15&17 Service users are supported to maintain family links ensuring family contact is kept. The arrangements at the home support service users to maintain family links. The meals at the home are adequate and offer variety and choice. EVIDENCE: The manager stated the home supported service users to maintain family contact and service users were able to see relatives in the privacy of their bedroom or the manager’s office. A review of care records indicated service users had regular visits from members of their family and the home had a visitor policy which supported family contact. The home had a menu plan and service users participated in, and were supported to help plan the menu and prepare meals. The menu plans were sampled which reflected variety, choice and well-balanced healthy meals. The home kept a record of meals eaten by service users which is good practice and consulted the dietician as appropriate for advice. One service liked rice dishes and another service user remarked he liked spaghetti Bolognese which were reflected on the menu. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 12 Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20&21 The arrangements for managing medications need to improve to promote the health of service users. The arrangements for managing ageing, illness and death of a service need to improve to ensure it is handled as the service user would wish. EVIDENCE: The home had a policy on medications and a service level agreement with a local chemist which supplied medications to the home on a monthly basis. Medications were appropriately stored in a locked metal cabinet and the home had a record of all medications received, administered and returned to the pharmacy. The inspector sampled medication record sheets and noted they had an up to date photograph of the service users and were dated and signed by staff with no discrepancies. A list of staff names with specimen signatures was available for information and homely remedies were approved by the GP. Training records were sampled which indicated a need for approved training in managing medications and documentary evidence was not available to support staff had training in medications. The manager and provider are in the process of arranging appropriate training and a requirement has been made to address this shortfall to promote the health of service users. The home had a policy on bereavement and staff had training in managing emotions in change, loss and bereavement. The inspector noted the care plans did have any information about the wishes of service users concerning Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 14 ageing, illness and death and the manager stated the provider had sent bereavement packs to obtain the views of families and friends about this issue. A requirement has been made to address this shortfall to ensure the ageing, illness and death of a service user is appropriately handled as the individual would wish. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The standards in this section were not assessed on this occasion. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27&30 The management of the home ensures service users live in a safe and comfortable environment. Toilets and bathrooms are adequate and provide sufficient privacy to meet the individual needs of service users. The systems for hygiene are satisfactory ensuring the home is clean and hygienic for service users. EVIDENCE: The standard of décor in the home has improved and the hallway has been decorated which makes it nice and attractive for service users. The home has good quality furnishings and fittings and adequate heating and lighting making it comfortable and safe for service users. The provider had manipulated the environment and installed under floor heating in a service user bedroom to minimise risks and promote safety. The home had adequate toilets and bathrooms which were lockable to provide privacy and a toilet was sited near the dining room and communal areas which was easily accessible to service users. The home had a policy on infection control and staff had attended a training course in the control of infection. The home had a washing machine and dryer which were in the utility room and the flooring was impermeable to make it easy to clean. Hand-washing facilities were prominently sited and anti-bacterial Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 17 hand-wash available in the home. The inspector noted the utility room was sited next to the kitchen and the manager had taken appropriate measures to prevent cross infection. The provider had a development plan to extend and separate the utility room and kitchen and the manager stated work on the project was due to start soon. On the day of the inspection the home was clean, hygienic and free from offensive odours. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35&36 The systems for training and development are satisfactory ensuring there is a staff training and development programme. The arrangements for staff supervision and support are adequate and ensure a well supported staff team. EVIDENCE: The provider is committed to training and development of employees and the company has produced a training plan dated 2006 and a development plan with a dedicated budget for staff training and development. The manager stated all staff received induction training and the inspector noted staff had completed the learning disability award framework (LDAF) training which included equal opportunities training. The home had a checklist to monitor staff progress towards induction training and allocated a named staff to supervise employees. The home had a policy on supervision of staff and the manager stated all staff received regular supervision. The inspector sampled supervision records and noted supervision was regular and records were dated and signed by the supervisor and supervisee. During discussions a member of staff stated “supervision was regular and in her opinion the quality was good”. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,41,42&43. The arrangements for quality assurance are satisfactory ensuring service users participate in the review and development of the home. Record keeping at the home is satisfactory and safeguards the rights and best interests of service users. The arrangements for safe working practices are satisfactory ensuring the health, safety and welfare of service users are promoted. EVIDENCE: The home had a policy on quality assurance and used questionnaires to obtain feedback about the home. The inspector noted the home had a quality assurance folder and completed questionnaires were dated March 2005. The provider made regular monthly visits to the home (Regulation 26) to check on the quality of the service and reports were sent to the Commission for Social Care Inspection (CSCI) for information. Requirements made from the previous inspection have been acknowledged and management action taken. The manager stated record keeping at the home is good and the inspector noted individual records and home records were accurate, up to date and in good order. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 20 The home had a policy on health and safety and the manager stated staff had attended a training course in health and safety. The inspector sampled training records and noted staff had attended training in first aid, fire safety, food hygiene and the home had records and inspection certificates for the gas boiler, fire alarm and equipment, legionella, emergency lighting and small appliances test certificate. Fridge and freezer temperatures were within normal limits and food was correctly stored. The home had a current certificate of employers liability insurance and the manager stated the business plan was kept at head office. A requirement had been made for a copy of the business plan to be sent to the commission for checking to ensure the financial viability of the home. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Upfield (1) Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 X 2 DS0000013441.V269959.R01.S.doc Version 5.0 Page 22 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 NMS-YA20 Regulation 13 (c) Requirement Timescale for action 01/04/06 2 NMS-YA21 12 (3) 3 NMS-YA35 18 (1)(a) 4 NMS-YA43 25 (2)(c) 25 (3)(c) The registered person must ensure staff have accredited training in managing medications and documentary evidence must be available to indicate such training has taken place to promote the health of service users. The registered person must 01/04/06 ensure care plans have a section concerning the ageing, illness and death of a service user to ensure it is handled as the individual would wish. The registered person must 01/02/06 produce an action plan outlining how National Vocational Training (NVQ) targets will be met ensuring service users are supported by a qualified staff team. The registered person must 01/04/06 ensure a copy of the business/financial plan is available at the home for inspection and a copy sent to the commission for information. Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Upfield (1) DS0000013441.V269959.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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