CARE HOME ADULTS 18-65
Lumley Road (16) 16 Lumley Road Horley Surrey RH6 7JL Lead Inspector
Kenneth Dunn Unannounced Inspection 31st January 2006 09:00 Lumley Road (16) DS0000013453.V284204.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 Lumley Road (16) DS0000013453.V284204.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. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 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.V284204.R01.S.doc Version 5.1 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 21st June 2005 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. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This visit was the home’s second inspection for the year 2005/2006. This was an unannounced visit, which meant that staff and residents were unaware that it was due to happen. The inspector was able to spend some time with residents that were at home. Some of the residents gave permission for the inspector to access their rooms and spoke about their day and life in the home. All of the residents who spoke with the inspector seemed happy living at Lumley Road. The inspector spent part of their visit in discussion with the member of staff on duty looking at cares plans, staff files, resident’s records and reports. What the service does well: What has improved since the last inspection? What they could do better:
This was a positive inspection with only one requirement being made to ensure that all staff have a practical awareness of all policies and procedures within the home, specifically to those procedures designed to protect the service users from abuse. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 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. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 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.V284204.R01.S.doc Version 5.1 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): The service continues to meet the core standard please refer to the previous inspection report dated 21st of June 2005. EVIDENCE: Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 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): 9 The service users clearly supported by the staff and have very independent and active lives. EVIDENCE: The staff member on duty informed the inspector that the service users enjoy an active and independent life style and freely access the community with or without the assistance of staff. It was further stated that the service only provides support to a resident if there is a perceived risk to the service user. The inspector reviewed a comprehensive set of risk assessments they were clearly set out and offered the reader a concise picture of potential risks and the out comes to the service users if no action is taken. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The organisation is dedicated to the concept of freedom of choice and assisting the service users to enjoy a fulfilling lifestyle. There is strong evidence to support this and the serviced users clearly benefit from being able to make independent choices about their lives and habits. EVIDENCE: The service users are all encouraged to make suggestions and to put forward ideas regarding the meals offered at the home. A Permanent item on the service users meeting agenda is the type and styles of food offered by the home. The inspector was informed that wherever possible the service users receive home-cooked meals. A log of meals was seen and indicated that the service indeed provides a well-balanced and nutritious diet for the service users. One service user has an educated palette for curries and he regularly asks for them as an alternative to the main meal of the day. The staff are very happy to organise a separate menu for him to ensure that he still has a healthy diet. The inspector was informed that this was not restricted to just one service users all of the residents can if they choose have an alternative meal. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 11 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 healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: The care plans and risk assessments evidenced that the majority of the service users are able to care for themselves but where necessary staff members will assist them. All service users are registered with the local GP and have access to all NHS healthcare facilities as required. Service users will receive support from members of staff e.g. offering support to and from appointments. Health records were seen as part of the inspection process. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 12 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): 23 Service Users are protected by the organisations training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: The inspector was informed that all staff currently working at the home have received in-house training regarding the protection of the service users from abuse or harm. However there was considerable confusion regarding the procedures to be actioned in the event of an incident occurring to one of the service users. The member of staff on duty was not sure where she would find any guidance in the event of an incident happening and was unaware of the Surrey Multi Agency Procedures. It is essential that all members of staff understand their role within the Vulnerable Adults Procedures (VAP). The manager is therefore required to ensure that all staff are aware of and can operate the VAP. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 13 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 & 30 The areas seen during the inspection were clean, well maintained and comfortable for the needs of the clients. EVIDENCE: The downstairs area of the home was inspected and offered a homely comfortable safe environment. The furnishings and fittings of the home were in good order. The home does not use any specialist equipment and the premises were clean and hygienic Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 14 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): The service continues to meet the core standard please refer to the previous inspection report dated 21st of June 2005. EVIDENCE: Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 15 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): 42 There was good evidence of areas of good management and practice within the home and service users are safeguarded by the home health and safety policies and procedures. EVIDENCE: The staff-training programme includes training in first aid, manual handling, fire safety, health and safety and basic food hygiene. The health and safety checks of the home including bath water temperatures, fire drills, and environmental health visit had all been maintained, however the certificates and records were not easily accessed or tracked down. It is recommended that all health and safety information should be stored in one file for ease of access, on the day of the inspection the member of staff on duty could not produce all Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 16 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 X 2 X 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 X 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X X X X 3 X Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 17 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 YA21 Regulation Requirement Timescale for action 31/03/06 10, 12, 13 All staff must be fully conversant & 37 with both the in house and Surrey’s Multi Agencies procedures for the Protection of Vulnerable Adults. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA41 Good Practice Recommendations The manger should ensure that all relevant documents are retained in an accessible place for the future inspections. Lumley Road (16) DS0000013453.V284204.R01.S.doc Version 5.1 Page 18 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
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