Inspection on 21/08/06 for 231 Stafford Road

This inspection was carried out on 21st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

231 Stafford Road 04/09/09

231 Stafford Road 06/09/07

231 Stafford Road 21/02/06

231 Stafford Road 05/10/05

231 Stafford Road 24/02/05

231 Stafford Road 07/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Stafford Road (231) 231 Stafford Road Wallington Surrey SM6 9BX Lead Inspector Deborah Yapicioz Key Unannounced Inspection 21st August 2006 12:30 Stafford Road (231) DS0000007214.V311854.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 Stafford Road (231) DS0000007214.V311854.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. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stafford Road (231) Address 231 Stafford Road Wallington Surrey SM6 9BX 020 8647 1271 0208 647 1271 manager.staffordroad@careuk.com 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) Care Solutions Limited Mrs Tina Edwards Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 people with a learning disability, 3 of whom may also have a physical disability. 21st February 2006 Date of last inspection Brief Description of the Service: 231 Stafford Road Wallington is a residential home for people with learning disabilities. Some service users may also have physical disabilities. The home is owned, managed and staffed by Care U.K. The premises are a modern two-storey building, with most bedrooms being on the ground floor. The service users all have a private bedroom. The home does not provide any emergency or respite provision. The communal space on the ground floor consists of an open plan living room, dining room and kitchen. There is a separate laundry room. There is also a small garden to the rear of the home as well as a patio area to the front. The office is situated on the first floor. The home is on a busy road, close to shops, parks and public transport. The home is within easy access of Sutton and Croydon. The home has its own mini-bus, which is accessible for wheelchair users. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2006/2007 and was an unannounced visit, which took place on 21st August 2006. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. Tina Edwards is the home manager who was not on duty at the time of the inspection. Jeanette Moore the deputy manager was on duty at the time of the visit and facilitated the inspection. Methods of inspection included meeting with the service users, a tour of the premises, and observation of contact between staff and service users and discussions with the deputy manager. Over the last twelve months the management team have kept the Commission for Social Care Inspection informed of any significant incidents involving the service users and the Croydon Office has received reports of the monthly visits carried out by the registered provider. Records examined during the inspection included service user plans, care manager assessments, risk assessments, medication records, complaints, staffing records, health and safety and fire records. The inspector would like to thank the service user, the staff team and Jeanette Moore for their help in facilitating the inspection What the service does well: What has improved since the last inspection? Each of the service users has an individual tailored care plan. The care plans are on the service users file and is a record of their aims and goals as well as their achievements. The home is in the process of introducing Person Centred Planning concepts to the care plan format, which is in keeping with current good practise. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stafford Road (231) DS0000007214.V311854.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 Stafford Road (231) DS0000007214.V311854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home provides good information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. EVIDENCE: 231 Stafford Road has a statement of purpose and a Service users guide in place. The deputy manager informed the inspector that the contents of both documents are reviewed regularly. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. The organisation also has its own assessment process for new service users. There have been no new admissions since the last inspection. A care manager’s assessment was seen on the service users files sampled during the inspection. Cultural and religious issues are addressed at the referral stage so that the service user and their family can be sure that those needs will be met. Compatibility with others already living in the home is also taken into account. Any prospective service user would have a gradual introduction to the home with a series of short visits and overnight stays. The time frame would be flexible depending on the service user. Stafford Road (231) DS0000007214.V311854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have comprehensive individual care plans with information on their needs and personal goals. Individual care plans include consultation with service users and reflect current needs and service users wishes. The home operates a risk management strategy thus enabling the service users to participate in activities with appropriate support. EVIDENCE: Each of the service users has an individual tailored care plan. The care plans are on the service users file and is a record of their aims and goals as well as their achievements. The home is in the process of introducing Person Centred Planning concepts to the care plan format, which is in keeping with current good practise. Records held on the service users files looked at during the inspection confirmed that the care plans are internally reviewed every six months and formally reviewed 12 months. The home operates a risk management strategy. Service users at the home have individual risk assessments depending on their needs and goals. Risk assessments covering various activities were seen on the service users files during the inspection including using the community. The home has a key worker system. The deputy home manager explained that part of the key Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 10 worker role is to advocate for the service user and involve them in the decision making process of the home. Service user views are important to the home and the staff team at the home encourage service users to make decisions about all aspects of their lives. The service users also have access to advocates and some service users attend a local self-advocacy group run by People First”. The service users spoken to during the inspection felt that the staff team listened to them. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. The service users have a varied programme of social activities organised by the staff team to reflect service users individual interests. The home has an open visitors policy to ensure friendships and family links are maintained. EVIDENCE: The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. The service users at the home are supported to access appropriate activities through local colleges and day centres where they have individual schedules of activities. Details of the service users daily activities and commitments are kept on the service users file and were seen during the inspection. The service users all have an annual holiday and on the day of the inspection two of the service users has just returned from holiday in the Portsmouth area, which they said they had really enjoyed. At the last inspection it was recommended that service users who would become upset if they spent time away from familiar surrounding should have Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 12 at least five individual days outing to places that are of interest to them. This recommendation will be carried over to the next inspection when the service users have all have had their holiday (or their days out). The home has its own transport. In house activities are also provided and one of the service users told the inspector that she enjoyed cooking and helping in the kitchen, other service users said that they enjoyed going to the park close to the house. The deputy home manager confirmed that service users have the opportunity to attend religious services if they wish. Family and friends are made aware of the home’s visiting policy and there are no restrictions regarding when family or friends can visit. Service users also visit their relatives. The home menus are based on the likes and dislikes of the homes service users. They also take into account the service users health issues. Snacks and hot drinks are available at any time during the day. Service users are offered an alternative to the main meal on offer if they choose. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have individual care plans, which include consultation with service users and their families. Care plans are regularly updated to ensure the service users changing needs are met. Residents’ medication is well managed to ensure good health, although there were some gaps in recording. EVIDENCE: The service users need varying degrees of assistance with their personal care. The level of support a service user needs would be detailed in their initial assessment and updated at review meetings and their preferred routines are set out in their individual Plan. Three of the service users are wheelchair users and water low assessments were seen on their medical records. The deputy manager informed the inspector that the home is in the process of introducing health action plans The staff team at the home monitor the health of each of the service users and would ensure they receive any treatment needed. A record of any General Practitioner and hospital appointments are kept on his file. The home provides consistency and continuity through designated key workers Incident forms are completed following any accidents. The home has a policy and procedure in place for the receipt, recording, storage, handling, administration and disposal of medication. There were some gaps in the medication records the time of the inspection. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. There have been no complaints since the last inspection. The home has a copy of the local authority Adult Protection Policy on site. The staff team have attended training on adult protection issues and a record is kept on their files. Discussions with staff members on duty confirmed that the staff team are aware of the action they must take if they need to report an incident. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 15 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): 24,26,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home provides a comfortable, clean and safe environment for service users to live in, however some of the carpets need to be replaced. EVIDENCE: 231 Stafford Road is a modern two storey building situated in Wallington. The house is well situated to access community facilities in Croydon, Wallington and Sutton. There is a park opposite the home. It is also close to rail and bus links. The home’s premises were accessible, in keeping with the local community and were suitable for their purpose. The communal areas of the room are clean and comfortable however several of the carpets in the service users bed room are stained and need to be replaced, particularly the carpets in the bedrooms, next to the lounge, at the end of the corridor and in the bedroom room next to it. There is also a split in the stained carpet in the hallway outside the laundry room, which could be a trip hazard and should be replaced. Each of the service users in the home has a single room. All of the rooms have been personalised and decorated to reflect their individual taste. Bedrooms viewed provided sufficient and suitable furniture. Service users spoken to during the inspection said they liked their bedrooms. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 16 The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The washing machine is capable of washing clothes at high temperatures, which helps with the control of infections. The laundry has suitable flooring. There is a locked cupboard for the Control of Substances Hazardous to Health products. On the day of the inspection the home was clean, bright and well ventilated. The home has policies and procedures on the disposal of clinical waste. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 17 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): 32,34,35, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home EVIDENCE: There are at least two members of staff on duty in the home at any one time. During the day when there are a lot of activities the manager arranges for three people to be on duty. At night there is one waking and one sleep in member of staff. The staff team at the home are issued with job descriptions, setting out the role and responsibilities of the staff at the home. It is company policy that all new employees are not permitted to start work until two satisfactory references from their previous employees have been confirmed. It is company policy that all new employees are not permitted to start work until two satisfactory references from their previous employees have been confirmed. Criminal Records Checks are also undertaken. The home has regular staff meetings; records of the issues discussed are on file at the home. The staff team must sign to say that they have read any policies and procedures. The staff team at the home receive supervision from the management team. New members of staff complete an induction programme covering various subjects including health and safety. Copies of staff induction were kept on file, which were available for inspection. Issues of respect and how to treat service Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 18 users with dignity is incorporated into the induction training of new staff. During the inspection staff were observed to be treating service users in a pleasant, friendly manner. Service users spoken to during the inspection felt that the staff team are nice to them treated them well and respected their privacy. The deputy manager informed the inspector that all staff have completed LADAF training and are enrolled (or have completed) a National Vocational Qualification course. Evidence of attending these courses was seen on the staff training files. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management style appears to be transparent with clear lines of accountability. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised. EVIDENCE: 231 Stafford Road is managed by Mrs Tina Edwards. Ms Edwards has worked in the field of learning disability since 1995 and has completed a National Vocational Qualification at level four. Ms Edwards was not on duty on the day of the inspection The home has self-monitoring systems in place such as a Quality Assurance audit carried out by “Care U.K.”, which takes place every year along with monthly regulation 26 visits. Copies of the regulation 26 visits are sent to the Commission for Social Care Inspection Croydon office. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 20 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. Administration and record keeping at this home is generally of a good standard. All staff must attend mandatory health and safety training including moving and handling. The home has a health and safety policy in place. Environmental risk assessments are in place. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house and fire drills are up to date. Coloured chopping boards and knives were seen in the kitchen. Health and safety law posters issued by the health and safety executive were also on display. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 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 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 YA20 Regulation 17 (1)(a) 33. (I) Requirement The registered person must ensure medication administration records are correctly filled in at all times. The home manager must ensure the stained carpets are replaced in the following areas: The service users bedroom at the end of the corridor and in the bedroom next to it. The carpet in the bedroom next to the lounge. The split and stained carpet in the hall way outside the laundry room. Timescale for action 21/08/06 2 YA24 23(2) 30/12/06 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 YA14 Good Practice Recommendations The home manger must ensure that all service users who do not go away on an annual holiday have at least five days out to places that are of particular interest to them. DS0000007214.V311854.R01.S.doc Version 5.2 Page 23 Stafford Road (231) A record of the activities should be kept on their file. Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Stafford Road (231) DS0000007214.V311854.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!