Inspection on 26/06/07 for 16 Lumley Road

This inspection was carried out on 26th June 2007.

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

Other inspections for this house

16 Lumley Road 18/07/06

16 Lumley Road 31/01/06

16 Lumley Road 21/06/05

16 Lumley Road 18/01/05

16 Lumley Road 06/09/04

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Insight - Eastchurch

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33 St John`s Church Road

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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 Lumley Road (16) 16 Lumley Road Horley Surrey RH6 7JL Lead Inspector Mary Williamson Unannounced Inspection 26th June 2007 10:30 Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 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 Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 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. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lumley Road (16) Address 16 Lumley Road Horley Surrey RH6 7JL 01293 782238 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.mencap.org.uk Royal Mencap Society Mr S Chandramurthi Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 - 65 YEARS, EXCEPT ONE OVER THE AGE OF 65 18th July 2006 Date of last inspection Brief Description of the Service: 16 Lumley Road is a detached house developed to provide accommodation for up to eight adults with learning disabilities, one of whom may be over the age of 65. The home is set in a residential area within walking distance from Horley town centre. All bedrooms are single occupancy and are decorated to a good standard. There is a pleasant garden to the rear of the property for the service users to enjoy. The home has some off road parking. The weekly fees for the home vary from £572.45 to £786.87. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over five hours. A senior support worker represented the home for the first half on the inspection and the Registered Manager Mr S. Chandramurthi was present for the second half of the inspection. A tour of the premises was undertaken and a number of records relating to the care of the residents and the management of the home were examined. Discussions were held with five of the residents, both individually and in small groups. They were all very keen to share their views of the home and were all happy to be living there. Discussions were held with the staff on duty. They were able to demonstrate an understanding of the needs of the residents and also able to confirm the training they had undertaken. The manager completed a detailed Annual Quality Assurance Assessment prior to the inspection and some of the information was sampled during the inspection. All six residents returned a care home survey with very positive comments about the home. Five relative or friend survey forms were returned and all were complimentary towards staff and the care provided. Three health care professional feedback forms were also received with positive comments on the home. The Commission for Social Care Inspection would like to thank the residents and staff team for their help and hospitality during the inspection. What the service does well: The home offers a good standard of individual and communal accommodation for the residents living in the home. The “support plans” in place outline the level of individual support required and are well written and reviewed regularly. The arrangements in place to meet the health care needs of residents are good and regular health checks are encouraged. Individual programmes of social and leisure activities are in place. The residents are very independent and enjoy a varied and active lifestyle. Risk assessments are in place for all activities in the home and community and do not restrict the independence of the residents. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 6 Staff recruitment procedures are good. Individual staff training and development programmes are in place and are ongoing to meet the resident’s needs. The home is well managed and there is good interaction between staff, residents and the manager. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 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 Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have access to the appropriate information to enable them to make an informed decision about living in the home. Needs assessments, and contracts of occupancy are in place. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place and all residents in the home have access to a copy of this. The residents spoken to were aware of this document and stated that this was discussed with them. The six residents in the home have been living there for several years. They all had a needs assessment undertaken prior to admission and these assessments are reviewed at least annually or more frequently when individual needs change. Three assessments were randomly assessed and were well maintained, and detailed. Contracts of occupancy are in place. Three of these contracts were seen. They outline the type of accommodation, which is provided by Hyde Housing Association, the support provided by MENCAP, and amount of fees payable and by whom. The content of these documents has been discussed with the individual residents who have signed and dated them. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are in place, which reflect individual care needs. Residents are encouraged to make decisions about their lives and risk assessments are in place. EVIDENCE: Individual care plans are in place. These are person centred and are called “support plans” in this home. These are written with input from the residents, and based on the assessment of needs. They are very detailed and include all aspects of personal, social, and emotional care. Regular reviews of care are undertaken and funding authorities also review care annually. Residents are supported to make decisions regarding all aspects of daily living. For example, residents choose what they eat, how they spend their leisure and recreational time, when they get up and go to bed. They also choose what structured activity they are involved in. Risk assessments are in place for all identified risks within the home and for community activity. These are detailed and do not restrict the independence to the residents. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have access to appropriate leisure, recreational and structured activities. Community and family links are maintained and nutritional needs are being met. EVIDENCE: All the residents have an individual programme of activities in place. For example, one resident explained how he helps in a local charity shop and also in the local newsagents, another resident stated that he gets the bus to work. One resident attends activities in The Croft resource centre and stated that he enjoys this very much. The residents live an independent lifestyle and access the local community with confidence. One resident went to the post office during the inspection to post a present to his mother. Another resident went out to lunch and for a trip to the park with a support worker using the home’s transport. All the residents had recently returned from a holiday in Canada and all talked enthusiastically of the experience. Some residents attend evening clubs including The Gateway, and The Oasis clubs. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 11 Residents are supported to maintain contact with family and friends. Visitors are welcome in the home and some residents can arrange to invite friends for dinner. Spiritual needs are supported and the manager stated that one resident recently stated that he would like to start attending church, which is in the process of being arranged. The nutritional needs of the residents are being met. The menus are planned at house meetings and there are a good variety of meals offered. There is a choice of breakfast with a cooked breakfast available at the weekend. Residents make their packed lunch when attending activities and the main meal is served in the evening. The shopping is done locally and residents are encouraged to help. There is free access to the kitchen and drinks and snacks are available throughout the day. One resident was busy peeling potatoes for dinner, and several helping to make tea. The kitchen has recently been refurbished and is clean and well equipped. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical, emotional, and health care needs of residents are met as outlined in individual “support plans”. Residents are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: The residents are mainly able to support themselves but supported is provided by staff when required as outlined in the “support plans”. All the residents are registered with a local GP and attend the surgery for appointments when required. Chiropody is provided by a practice in Albert Road, and residents visit a local dentist regularly. One resident stated that he could visit the optician in the local town when he requires new glasses. There is a policy in place for the administration of medication and all staff have training in this. Medication is provided by Boots the Chemist in blister pack format. They also undertake regular audits of medication within the home. The medication recording charts were seen and these are well maintained. Currently there are no residents in the home that self medicate. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure and the abuse awareness procedure in the home protect residents living there. EVIDENCE: There is a complaints procedure in place and all residents have access to a copy of this, which is also available in symbol format. Residents are aware of this and stated that they would be able to make a complaint if necessary. The manager stated that there have been no complaints since the last inspection and that “minor niggles” are solved immediately. There is an abuse awareness policy in place and all staff undertake training in this policy during induction training. Both staff spoken to are aware of this procedure and how to implement this. There is also a copy of Surrey’s Multi- Agency Policies and Procedures for the Safeguarding of Vulnerable Adults in place. The manager and a senior support worker have attended the local authority training in these procedures and have cascaded this training throughout the staff team. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, well-maintained and homely environment, which is hygienic and meets their individual and collective needs. EVIDENCE: The inspector and a resident undertook a tour of the home. There is a newly refurbished dining room, which is well furnished providing a bright and airy atmosphere. The lounge has also been recently decorated and is well furnished. There is a large garden to the rear of the home, which is well maintained by the residents. Some residents invited the inspector to visit their rooms, which are all comfortably furnished, and personalised to reflect individual personalities and hobbies. One room was equipped with a desk and lamp to support that resident with his excellent sketching work. The home is maintained to a high standard and is clean and hygienic. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A staff team who have the appropriate skills and training to meet their needs supports residents. The recruitment procedures protect residents. EVIDENCE: The duty rota was seen and the number and skill mix of staff was sufficient to meet the assessed needs of the residents. Additional staff are provided when required to support residents with individual activities. Individual staff training and development programmes are in place. All staff undertake induction training and evidence of this was sampled in staff files. Mandatory training includes health and safety, moving and handling, fire safety, food hygiene, abuse awareness, risk assessment, and medication safety. NVQ training is ongoing, with some staff having achieved NVQ level 3 and other staff undertaking NVQ level 2. The recruitment procedure in place protects the residents living in the home. Three staff employment files were randomly sampled. These are well maintained and include an application form, two written references, an employment history and a CRB (Criminal Records Bureau) disclosure. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home, which is operated in their best interests, and promotes health, safety, and welfare. EVIDENCE: The home is well managed by an experienced manager. He also has achieved his Registered Manager Award. He has a sound understanding of the needs of the residents he supports. Five of the residents spoken to all felt confident in the management structure within the home and this was evident by the good interaction observed between the manager, residents and staff. The systems in place to monitor quality assurance are good. Weekly house meetings take place and any suggestions or concerns are discussed and resolved. Records of these meetings are retained in the office. The service manager undertakes monthly quality review visits. This generates a Continuous Improvement Plan concentrating on Making the support even better. Making the team even better. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 17 Making the system even better. Making the environment even better. Questionnaires are sent to residents for feedback on the service provided. Health and safety are promoted and all staff undertake health and safety training as part of their induction training. COSHH procedures are observed. The fire safety systems in place protect the residents. The alarms are tested weekly and there is a contract in place for the maintenance of fire fighting equipment and emergency lighting. Appropriate health and safety checks are maintained on various facilities and equipment in the home and the required certificates are in place. Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 18 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Lumley Road (16) DS0000013453.V339485.R01.S.doc Version 5.2 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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