Inspection on 21/11/05 for 1 Upfield

This inspection was carried out on 21st November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 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 19/01/06

1 Upfield 26/01/05

1 Upfield 27/07/04

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Southfields

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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 Announced Inspection 21st November 2005 10:00 Upfield (1) DS0000013441.V256466.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.V256466.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.V256466.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.V256466.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 detached house situated in a residential area in Horley within walking distance to the town centre and close to public amenities. The home provides accommodation for six male service users with learning disabilities aged between 18 and 45 years. Accommodation is provided in single bedrooms and set out on two floors. The home has a communal sitting room, a kitchen adjoining the dining room, a laundry and there is a secure garden to the rear of the property. Private parking is available to the front of the property. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of 7 hours. A tour of the premises took place and staff and service users were spoken to. Documents and care records were examined. Some of the service users who live at the home have communication difficulties and the inspector made judgements based on their mood and behaviour. The inspector would like to thank the manager, deputy manager, staff and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must review and amend the support plan of one service user to take account of behavioural and physical interventions. The heating in the bedroom of one service user must be improved to ensure it is adequate and meet his needs. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 6 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.V256466.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.V256466.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): 1,2,3,4&5. The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services the home provides enabling an informed choice to be made about the home. The arrangements for needs assessment are satisfactory ensuring service users needs are assessed and identified. The arrangements at the home for meeting the needs of service users are adequate. The system for introductory visits to the home is satisfactory ensuring prospective service users have an opportunity to visit and test drive the home. The arrangements for contracts are satisfactory ensuring the tenancy rights of service users are protected. EVIDENCE: The home had a statement of purpose that had details about the aims, objectives and philosophy of the home. The inspector noted it was reviewed and amended in 2005. The service user guide had information about the purpose of the home and following a review in 2005 information was added on the use of the telephone, office and mealtimes. The manager stated service users were involved in developing the service user guide that was in widget format. The home had an admission policy dated 2005 and a person centred plan based on the homes own needs assessment. The inspector sampled the person centred plans and noted it had information on the health needs of service users. The manager stated the home had the capacity to meet service Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 9 needs by involving other health care professionals. The inspector noted the home had input from a psychiatrist and the specialist support and development team. Staff had training in autism and makaton to help them communicate effectively with service users. The home had a charter of rights that reflected prospective service users and their relatives were able to visit the home, have a meal and meet service users and staff. The manager stated the home offered contracts to service users that were sampled. The inspector noted a contract dated August 2005 had been signed by the service user, provider and placing authority. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 10 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): 6&9 The arrangements at the home for risk taking are adequate ensuring service users are supported to take risks as part of an independent lifestyle. The systems for assessing needs are satisfactory ensuring service users personal goal are reflected in their care plans. EVIDENCE: The manager stated the home had care plans, person centred plans and health action plans. The inspector sampled a care plan dated 30/4/05 and noted a review had been arranged for 30/11/05. The inspector noted a service user who wanted to lose weight had a health action plan dated May 2005 and covered nutrition, fitness, mobility and weight. An annual review dated 9/5/05 had involved the care manager, relatives, key worker and manager. The manager stated the home supported service users in risk taking. The inspector noted the home had a policy on risk assessment dated 2005 that included house risk assessments and personal risk assessments. The inspector noted the manager had completed a decorating and maintenance risk assessment dated 8/11/05 to reflect the current refurbishment of the home. Risk assessments were dated and signed by staff and a risk assessment on bathing dated 7/9/05 was completed by the deputy manager and signed by the Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 11 manager. During a meeting staff stated care plans and risk assessments are constantly reviewed at team meetings. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 12 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): 12,13,14&16 The arrangements for education at the home are satisfactory ensuring services users are supported in fulfilling activities. The systems at the home ensure service users are supported to maintain community contact. The arrangements for activities are adequate ensuring service users have appropriate leisure opportunities. The daily routine at the home is satisfactory ensuring service users rights are respected. EVIDENCE: The manager stated service users were supported to take part in education and occupation. The inspector sampled service users activity plans that were individualised and noted one service user attended Central Sussex College twice a week to do cookery and art and another service user had a work placement and did data entry on files and on computer. The manager stated the home supported service users to maintain community links and staff supported service users to use local shops, pubs and cinema that was reflected in the care plans. The inspector noted the home employed staff with African ethnicity to reflect the cultural diversity of service users that are afrocarribean. The inspector noted one service user had membership at a local Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 13 hotel to use the leisure facilities and went swimming regularly and another service user went to Reigate to buy stamps. The manager stated staff respected the rights of service users that were reflected in care plans. The inspector noted staff addressed service users by their preferred names and the manager knocking on doors before entering service users bedrooms. During the inspection staffs were observed to interact with service users and the inspector noted the manager supported a service user to keep a record of his personal finances. The inspector noted service users had unrestricted access to the home and one service user was invited to the office to use the computer. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 14 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): 18&19 The arrangements at the home for personal support are satisfactory ensuring service users are supported in the way they prefer. The systems for assessing healthcare are satisfactory ensuring service users health needs are met. EVIDENCE: The home had a policy on privacy and dignity dated 2005. The inspector noted the manager had put in place guidelines dated November 2005 to support service users regarding personal hygiene that covered the bathroom, shower room and toilet areas. The home operated a key worker system and key workers attended a training course on autism to enable them to communicate with service users that is reflected in care plans. The inspector noted service users were encouraged to choose their own clothes, were appropriately dressed and supported by staff from the same ethnic and cultural background. The manager stated service users were registered with a local GP and the home had psychiatric input from the local primary care trust. The inspector sampled records and noted the home had a contract with Clerklands Surgery in Horley that provided an asthma nurse to monitor the health of one service user. The inspector noted one service user had a flu jab on the 25/10/05 and his teeth cleaned and checked under general anaesthetic in August 2005. The inspector noted staff supporting a service user in healthy eating to encourage him to manage his weight. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 15 Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 16 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): 22&23 The complaint process at this home is good with complaints information available to staff, service users and relatives. The arrangements for the protection of service users are satisfactory ensuring the welfare of service users is protected however the use of physical restraint must be reviewed and care plans updated. EVIDENCE: The home had a complaint policy dated August 2005 that is in a widget format to make the information accessible to service users. The manager stated the home kept a record of complaints that were sampled. The inspector noted three complaints were recorded in 2005 and management action had been taken. The home had a whistle blowing policy dated August 2005 that was signed and dated by staff and a policy on abuse, sexuality and relationships. The manager stated staff had training in the protection of vulnerable adults and noted the home had the local authority (Surrey County Council) procedures on the protection of vulnerable adults dated February 2005. The manager stated staff used physical restraint to support one service user that was recorded in the care plan. The inspector sampled the care plan and noted the guidance did not specify how the service user is to be restrained that was discussed with the manager and action has been required in respect of this matter. The manager remarked staff had restraint training that was reflected on the homes training plan. During a meeting staff stated they were aware of the complaint and whistle-blowing policies and remarked policies and procedures at the home are regularly reviewed. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 17 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): 24,25,26,28&29 The arrangements for the maintenance of the premises are adequate ensuring the home is comfortable and safe. The arrangements at the home ensure service users bedroom suits their needs and lifestyle and promote their independence. However, the heating in one service user bedroom must be improved. The toilets and bathrooms at the home are adequate ensuring sufficient privacy for service users. The shared spaces at the home is satisfactory ensuring service users have adequate space to complement their individual rooms. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from offensive odours. The manager stated the home had a development plan and the provider produced the plan during the inspection. The inspector noted the entrance and hallway was being decorated. The manager completed a risk assessment to ensure the safety of staff and service users whilst the home is being decorated. Furnishings and fittings were adequate. The manager stated service users had single bedrooms and the inspector noted bedrooms were personalised with pictures, paintings, bookcases, books, CD and television. One service user had his bedroom decorated in blue that is his preference and Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 18 another service user stated he chose the colour of his bedroom. The inspector noted a service user bedroom was untidy that reflected his needs and lifestyle and another service user had his wardrobe secured to the wall to maintain safety. The heating in one service user bedroom was inadequate that was discussed with the manager and action has been required in respect of this matter. The shower room, toilets and bathrooms were refurbished to make it nice and attractive for service users and the home had a kitchen, dining area, a lounge and adequate laundry facilities. The communal lounge was nicely decorated and furnished with settees, good light fittings, television, DVD player, pictures and paintings. The garden was well maintained, private, secure and easily accessible. The home had no specialist adaptations or aids and this standard was not assessed. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 19 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): 32,33,34&36 The arrangements at the home for staff training are satisfactory ensuring service users are supported by competent staff. The arrangements for allocating staff are adequate ensuring service users are supported by an effective team. The recruitment procedures are good ensuring the welfare of service users is protected. The systems for supervision are good ensuring service users benefit from a well-supported staff team. EVIDENCE: The manager stated staff have the skills and experience necessary for the task they are expected to do. The inspector noted two staff doing the registered manager award, three staff with the NVQ level 3 in care qualification, and staff LDAF trained. Observations confirmed staffs were good listeners and the inspector noted the manager taking time out from her management duties to support a service user that was anxious. The manager stated the home had good staffing levels and the inspector noted on the day of the inspection the manager, deputy manager and three carers were on duty that was reflected on the duty roster. The inspector sampled the duty rota for the period 22/11/05 and noted on Tuesdays and Thursdays five staffs were booked on duty to support service users in community activities. The home had regular staff meetings that were sampled and the inspector noted the last meeting was held on the 8/11/05 attended by 9 staff. The inspector noted the staff team reflected the cultural composition of service users and was made up of staffs of white, Asian and African ethnicity. The home had a policy on recruitment Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 20 dated August 2005. The inspector sampled recruitment files and noted it contained completed application forms, two references, CRB disclosure numbers, terms and conditions of employment and a health questionaire. The home had a recent photograph of staff that was kept in the training file. The home had a policy on supervision dated August 2005 and a supervision database form dated 2005 that is used by the manager to monitor the frequency of staff supervision. The inspector sampled supervision records and noted they were dated and signed by the supervisor and supervisee. One supervision record was dated 27/10/05 and the next supervision date was booked in the homes diary. During a meeting staff stated they had regular supervision and were given a choice of venue, some staff commented the arrangement to have supervision outside the home is a good policy by management. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 21 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): 37,38&40 The arrangements for the management of the home are satisfactory ensuring service users benefit from a well run home. The management approach of the home is adequate creating an open atmosphere for the benefit of service users. The policies and procedures of the home are good ensuring the rights of service users are protected. EVIDENCE: The home has an experienced manager who has been in post for five years. The manager has an NVQ Level 4 in management and is currently doing the registered manager award and is an NVQ assessor. The inspector noted the manager is aware of her responsibilities and stated she had responsibilities to ensure the policies and procedures of the home were implemented, the budget is properly managed and the objectives of the home are met. The manager stated she had a participative and democratic management style and consulted with staff regularly using supervisions and team meetings. The inspector noted the management approach was open and staffs were included in Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 22 decision-making about activities and the plan of the day. Observations confirmed service users were comfortable with the management style of the home and the inspector noted service users and staff sitting together in the lounge having mid-afternoon tea and doing activities. During a meeting staff stated we are always trying out new ideas that we bring to the attention of senior management. The inspector noted the company’s policies and procedures were up to date and the home’s procedures were regularly reviewed dated and signed by staff. The manager stated staffs have access to policies and procedures that were kept in a folder in the office. Staffs commented policies and procedures are regularly reviewed with senior management. Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 23 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 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Upfield (1) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X X X DS0000013441.V256466.R01.S.doc Version 5.0 Page 24 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-YA23 Regulation Requirement Timescale for action 01/01/06 2 NMS-YA23 12(1)(a)(b) The registered person must 13(7) ensure the use of physical restraint on a service user is clearly defined and recorded in the service user care plan. 23(2)(p) The registered person must ensure an appropriate radiator is installed in a service user bedroom to provide adequate heating. 20/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Upfield (1) DS0000013441.V256466.R01.S.doc Version 5.0 Page 25 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.V256466.R01.S.doc Version 5.0 Page 26 - 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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