Inspection on 25/04/06 for 122 Green Lane

This inspection was carried out on 25th April 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

122 Green Lane 23/08/07

122 Green Lane 24/10/06

Similar services:

Belle Vue Country House

Crossways Community

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Green Lane (122) 122 Green Lane Addlestone Surrey KT15 2TE Lead Inspector Mary Williamson Unannounced Inspection 25th April 2006 10:30 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Green Lane (122) Address 122 Green Lane Addlestone Surrey KT15 2TE 01372 722970 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) www.together-uk.org Together Working for Wellbeing To Be Confirmed Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Green Lane is a substantial converted property providing accommodation and nursing care for twelve service users with a mental health disorder. The home was formally owned by Welmede Housing Association. It has recently changed ownership and was registered on 1st April 2006 with “Together” as the new providers. The home is located in the village of Addlestone within easy access to the local shops and facilities. The accommodation is provided in single en-suite rooms. There is ample communal space, which includes a dining room, and two lounge areas one of which is used as a smoking area. There is a large garden accessible to the service users situated to the side of the building. There is also ample parking facilities at the front of the home. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the first inspection at 122 Green Lane under the new management structure. The home was formally owned by Welmede Housing Association and registered under the new providers “Together” on April 1st 2006. Mary Williamson the Lead Inspector for the home undertook the inspection. The acting manager Robert Ross was the designated representative for the service and was present throughout the inspection. Informal discussions were held with groups of service users, and also on an individual basis. The general feedback was that of relief following the transition of the home from the old provider to the new. Some service users stated that they felt more settled now that the air of anxiety and uncertainty had passed. Two service users also stated that they were looking forward to having more staff, as they will be able to take part in more leisure activities. The inspector had the opportunity to walk in the garden with a service user who was optimistic about restarting his garden project with his key worker. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. Staff were spoken to in groups and individually. There has been considerable staff movement during the take over period with some staff leaving and more joining the staff team from other projects in the organisation. It was good to note a positive attitude within the staff team. Even though the environmental standards of the home do not meet the National Minimum Standards, it was very encouraging to note the amount of work that has been undertaken since the last inspection to improve the quality of the environment for the service users living in the home. Requirements have been made in this report relating to the premises. The inspector would like to thank the service users, and staff team for their positive input to the inspection process. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The general standard of cleanliness and hygiene in the home is poor and needs to be addressed. The acting manager stated that a cleaner is due to start employment once all required employment documentation is in place. The lack of permanent staff in the home prevents service users from undertaking regular activities. The acting manager stated that recent recruitment of staff had taken place and they were expected to commence employment within a month. The external and internal window frames need to be repaired and repainted. The exterior walls of the home need to be painted. A service user guide needs to be developed and a copy given to all service users. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 7 A complaints procedure also needs to be introduced and a copy available to all service users. 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. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 8 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 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 9 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, and 5, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new statement of purpose and service user contract provides service users with some information regarding “Together”. A service user guide is in the process of being developed. A new assessment format in place allows for prospective service users aspirations and needs to be assessed. EVIDENCE: The organisation has produced a statement of purpose for 122 Green Lane setting out the aims, objectives and philosophy of the home. This must also include a service users guide outlining clear and accessible information regarding the all aspects of the home and facilities offered. There is a clear contract of terms and conditions of occupancy in place and all service users have a copy of this. The current group of service users have been living in the home for a considerable length of time and all have a needs assessment in place. The acting manager was able to demonstrate a new assessment format recently developed which will be used for all further admissions to the home. This is detailed and includes all aspects of care to be provided and the treatment and rehabilitation programmes to be followed. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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, 7, and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans are in place for all service users. These need to be updated to include the new organisations philosophy of care, aims, objectives and risks involved. Staff support service users to make decisions regarding daily living and home life. EVIDENCE: Individual care plans are in place which are based on needs assessments, and individual input from service users. These care plans are signed by service users and reviewed at least monthly. Following a discussion with the acting manager it was recommended that all care plans are rewritten at the next review using the new organisation’s philosophy of care and new stationary. Formal reviews of care take place every four months and are attended by the service user, GP, Psychiatrist, Care management, relatives and staff team. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 11 Service users are given the opportunity to participate in the daily running of the home. One service user likes to lay the dining tables for meals, and another likes to wash up. Some service users are included in the food shopping, and menu planning. House meetings are actively encouraged. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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, 15, 16, and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Currently there is limited opportunity for service users to expand on personal development, and participate in community activities. Family links are maintained, and the nutritional needs of the service users are met. EVIDENCE: Some service users have individual activities programmes in place, which include one attending a local activities day centre for three days a week. One service user attends a computer class on Friday. Community links include visits to the local shops, visiting the local golf club for coffee, and one service user likes to access the local hairdresser on a regular basis. A discussion took place in the lounge with a group of service users who all stated that that more activities were necessary. There are no home entertainment facilities available and one service user stated that he would like to have the user of a DVD recorder and a music centre. Another service user stated that she would like to have a TV in her bedroom. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 13 One service user was observed to exhibit attention seeking behaviour and was very anxious to go out shopping. She was reassured that when more staff were available in the afternoon than this would be possible. A discussion took place between the inspector and the acting manager regarding the development of a stimulating activities programme for all the service users in the home. He informed the inspector that this would be implemented within a month on the employment of new staff, and when the management team have made a decision regarding a lease car. Family links are well maintained and relatives are encouraged to visit the home at any reasonable time. Relatives have been fully involved in the recent transition of providers. The acting manager stated that a relative steering group meet regularly, and this is also attended by a consultant and PCT representative. The next meeting is on 12th May 2006. There has been regular communication between the inspector and the relatives group during the recent transition of the service. Service users plan the menus with staff support, and some service users help with the weekly shopping. A healthy eating plan is encouraged to enable some service users reduce their weight which is a side effect of taking psychiatric medication. It was very encouraging to note that the kitchen has now been refitted and new equipment installed. The large industrial cooker needs to be steamed cleaned in line with health and safety procedures. The home needs to employ a cook to manage the catering arrangements, and to prepare and cook the evening meal. This is an outstanding requirement. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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, and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate support to the service users to ensure that all their health and personal care needs are being met. EVIDENCE: Personal care and support is offered to service users in a sensitive manner as outlined in individual care plans. Service users are registered with a local GP, which remains unchanged following the transition of the service. Some of the service users stated that were very pleased about this, as they did not want to change their doctor. The acting manager stated that all the service users had to register with a new dentist at Goldsworth Park NHS Dental Surgery as their former dentist now only treats private patients. The service users questioned did not have a problem with this arrangement. Psychiatric support will continue as before. The home does not have a medication procedure in place. A requirement has been made for the home to develop a policy and procedure for the administration of medication in line with the NMC code of conduct. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 15 The local chemist who also undertakes medication audits supplies medication. The medication recording charts are well maintained. Currently there are no service users who undertake self -medication. Several service users have two weekly injections by staff qualified to administer this. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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, and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home does not have a current complaints procedure in place to enable service users to make their views known. Service users are protected from abuse. EVIDENCE: Since the transition of the home there is not a current complaints procedure in place. However when questioned the service users were aware of the old complaints procedure. A requirement has been made accordingly. There is an abuse awareness policy in place, and the home also has a copy of Surrey’s Multi-Agency Policies and Procedures on the Safeguarding of Vulnerable Adults in place. Training is ongoing in these procedures. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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, 27, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home’s premises dose not promotes a well maintained, hygienic, and homely environment. EVIDENCE: The standard of decoration varies throughout the home. The entire wooden window frames both externally and internally need to be repaired and repainted. The exterior walls of the home need to be repainted. The acting manager stated that a budget had been identified for this purpose. The communal lounges and dining rooms are now refurbished. The non smoking lounge is bright, clean and well maintained. The smoking lounge needs additional lighting, as it is too dark. Most of the bedrooms floors have had new floor covering, and the requirements relating to the fixtures and fittings in individual rooms have been met. Some individual bedrooms have been personalised to reflect individual personalities. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 18 Some service users smoke in their bedrooms, which is a fire risk and must be reflected in all care plans and insurance documentation. Bedroom 7 despite having been redecorated remains in a state of disrepair, and will continue to be monitored on an individual basis with the management of the home. The general standard of cleanliness and hygiene in the home remains poor. Some individual service users maintain their own rooms to a good standard, while other bedrooms, en-suite bathrooms and shared toilets need to be thoroughly cleaned by a cleaner on a daily basis. The acting manager stated that a cleaner had been employed and will start employment once all the required employment checks have been undertaken. It is a requirement that a cleaner is employed immediately to maintain an acceptable standard of hygiene in the home for the health and welfare of service users. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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): 31, 34, and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit tot the service. The current staff team is not sufficient to support the service users living at the home. The recruitment procedure in place protects the service users. Staff training is ongoing. EVIDENCE: The staff duty rota was seen and the number and skill mix of staff on duty during the inspection was sufficient to meet the physical needs of the service users. A discussion with the acting home manager relating to the duty rota highlighted the shortage of permanent staff and the dependency on bank staff within the home. Three staff are on duty throughout weekdays, and two at the weekends, who are overseen by a nurse in charge. There are two staff employed for the night shift, one of whom is a qualified nurse. The complex needs of the service users and the lack of leisure activities indicates that the home is not adequately staffed to meet the psychological and emotional needs of the service users. The acting manager stated that this had been recognised and new staff are due to stare employment within a month. A requirement has been made accordingly. The recruitment procedure in place protects the service users within the home. The employment files seen contained all the required documentation necessary and the files were well maintained. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 20 The home has an induction- training programme in place with all new staff undertaking this training and a record retained on individual files. The acting manager stated that the organisation engage Guildford College to provide a distance learning course of twelve weeks for medication training. One member of staff has an NVQ Level 2 and one staff has an NVQ level3. Another staff member is working towards NVQ level 4. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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, and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. An experienced acting manager in the best interests of the service users is currently managing the home. The health and safety of the service users is promoted and protected. EVIDENCE: An experienced manager registered with The Commission for Social Care Inspection for another project within the organisation currently manages the home. He has an NVQ level 4 in management and is a qualified assessor. There deputy manager’s post is currently vacant. The manager has been working in the home for eight weeks and had a period of working with the outgoing manager. Together must employ a manager for the home and submit an application to register the manager with The Commission for Social Care Inspection as soon as possible. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 22 There is a wide range of policies and procedures in place and all staff heve ongoing training in these procedures, which includes first aid, food hygiene, risk assessing, fire safety, and COSHH. Staff confirmed they have regular training update in these procedures. The fire safety records were seen and these are well maintained. Fire alarms are checked weekly, and contracts are in place for the maintenance of fire fighting equipment. A new fire-detecting panel has been installed in the front hall. Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X X X X 3 X Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 24 YES 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 YA1 Regulation 5(2) Requirement The registered person shall supply a copy of the service users guide to The Commission and each service user. The registered person shall ensure that the service users care plan is kept under review The registered person must consult with service users about their programme of activities and make arrangements to enable them to engage in activities The registered person shall make arrangements for the recording; handling, safekeeping, administration and disposal of medicines received into the care home, and must produce a medication policy. Timescale for action 20/07/06 2 YA16 15(2)(b) 20/07/06 3 YA12 16(2)(m) 20/07/06 4 YA20 13(2) 20/07/06 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 25 5 6 7 8 The registered person shall produce a complaints procedure for use in the home. YA30YA27YA25YA24 23(2)(b)(c)(d) The registered person must ensure that the care home is kept in a good state of repair externally and internally. That equipment used in the care home is maintained and in good working order, and all parts of the care home is kept clean and reasonably decorated. YA31 18(a)(b) The registered person shall ensure that all times suitably qualified, competent, and experienced staff are employed in the care home inn such numbers as are appropriate for the health and welfare of the service users. Ensure that the employment of temporary staff will not prevent the service users from receiving continuity of care. YA37 8(1)(b) The registered provider shall appoint an individual to manage the care home where the registered provider is an organisation. YA23 22 20/07/06 20/07/06 20/07/06 20/07/06 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 26 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 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 27 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 Green Lane (122) DS0000066920.V292232.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!