Inspection on 06/09/07 for 231 Stafford Road

This inspection was carried out on 6th September 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

231 Stafford Road 04/09/09

231 Stafford Road 21/08/06

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:

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Edenvale

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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 18-65 231 Stafford Road Wallington Surrey SM6 9BX Lead Inspector Emma Dove Key Unannounced Inspection 6th September 2007 11:15 231 Stafford Road DS0000007214.V348782.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 231 Stafford Road DS0000007214.V348782.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. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 231 Stafford Road Address Wallington Surrey SM6 9BX 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) 020 8647 1271 0208 647 1271 manager.staffordroad@careuk.com Care Solutions Limited Mrs Tina Edwards Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 2. Physical disability (PD). The maximum number of service users to be accommodated is 6. Date of last inspection 21st August 2006 Brief Description of the Service: 231, Stafford Road is a registered care home for people with learning disabilities who may also have physical disabilities. Five people are currently living there. The home is owned, managed and staffed by the organisation Care U.K. Accommodation is provided over two floors. All bedrooms are single. Communal space consists of an open plan living room, dining room and kitchen. There is a separate laundry room. 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. Stafford Road is a busy road, close to shops, parks and public transport with easy access to Sutton and Croydon. A mini-bus, which is accessible for wheelchair users is available. Information about the CSCI is included in the Statement of Purpose and Service Users Guide. The fees vary depending on people assessed needs, details are available from the home. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over six hours on the 6th of September 2007 by one regulation inspector. The inspection included looking at records, looking around communal areas and four bedrooms, talking with people who use the service, staff and the registered manager. An Annual Quality Assurance Assessment was returned in good time to be included in this report. No other information has been received from the home. What the service does well: What has improved since the last inspection? What they could do better: Update the Statement of Purpose and Service Users Guide to ensure people have correct information about staff at the home. A copy of the monthly visit by the registered person must be sent to the CSCI to provide regular information about the home and the quality assurance systems in place. Records should indicate that work has been completed on the electrical supply after the check in 2003. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 231 Stafford Road DS0000007214.V348782.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 231 Stafford Road DS0000007214.V348782.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 and 2 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose and Service Users Guide to provide information to people about the services provided. A full assessment is carried out before admission. EVIDENCE: A Statement of Purpose is in place, it contains information about who the service is provided to, the organisation, staff, activities, consultation and some of the relevant procedures including how to make a complaint and details of the CSCI. This requires updating to reflect current staff. The Service Users Guide is in pictorial format which is accessible to people who use the service. This document contains information about support, decision making, room keys, leisure pursuits, the individuals key worker and how to contact the CSCI. Assessments were seen in case files and include the support and assistance individuals need. These have been kept under review and updated when necessary. 231 Stafford Road DS0000007214.V348782.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 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Care plans are person centred, have been developed from assessments and are completed with the individual. A key work system is in place, which enables staff to work on an individual basis and be involved in goal setting. EVIDENCE: Care plans contain detailed information about people’s needs, wishes and their social and medical history. Separate Person Centred Plans (PCP) have been developed with individuals that include goals to be achieved and an action plan of support required to meet those goals. The manager reported that they are still developing the PCP and need to add photographs. Daily recording includes details of daily living skills and tasks completed. Reviews were seen to have been held on a regular basis although the notes were not always in the individual’s file. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 10 Monthly key work sessions were recorded. People who use the service confirmed that they see their key worker regularly to discuss any changes, any concerns and any plans for the future. Risk assessments are in place and have been updated. 231 Stafford Road DS0000007214.V348782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service is committed to enabling people who use the service to develop and maintain social, emotional and independent living skills. People have been supported to develop goals and are working towards achieving them. People have the opportunity to develop and maintain important personal and family relationships. EVIDENCE: People using the service confirmed that they are involved in daily living tasks and they feel that this is appropriate. Some people who use the service go to day centres, while other people go to sessions at a day centre, depending on their needs and choices. Some people attend adult education sessions. Everyone has two sessions with a physiotherapist every week and an aromatherapist sees everyone weekly. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 12 People who use the service have one week day at the home to complete household tasks and have individual time with staff doing an activity. People said that they are happy with the level of activity available to them. At the last inspection a recommendation was made for all people who use the service to have the opportunity to stay away from the home or have day trips in the place of a holiday. The manager reported that some people who use the service had chosen some places and activities instead having a weeks holiday. One person confirmed that this had worked well and were looking forward to their next special trip. One person reported that they attend church regularly and that staff support them to do this, which is important to their life. The manager reported that other people who use the service attend church services of their choice. One person said that they had celebrated their Birthday in the way they had chosen. The manager reported that people who use the service are supported to maintain relationships with family members and friends. Meals are varied and meet peoples medical and religious needs and food preferences. People who use the service were seen to be involved in meal preparation and confirmed that this was important to them. People also confirmed that they can access the kitchen and make drinks and snacks when they choose. 231 Stafford Road DS0000007214.V348782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The health care needs of people who use the service are clearly recorded. People have access to appropriate healthcare professionals. Health needs are monitored and appropriate action taken. Medication is well managed, records are completed in full and signed. EVIDENCE: Health plans are in place which indicate that people using the service have access to health professionals in the community including the dentist and optician. Records are kept of health appointments and any actions required. Staff were seen to pass information to other staff about health appointments and actions to be taken. One person said ‘staff listen and offer help as required’. Staff are aware of privacy and dignity issues, but should take more care when speaking with people who use the service to maintain privacy. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 14 Appropriate medication policies, procedures and practices are in place. Medication is labelled and stored correctly. Medication Administration Record Sheets were up to date and signed by staff. Staff receive training in the administration of medication, the manager also completes a competence test on staff before they administer medication. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 15 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 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has a clear complaints procedure which is accessible to people who use the service and their relatives or representatives. Policies are in place for the protection of vulnerable adults. Staff complete training in adult protection. EVIDENCE: The complaints procedure is included in the Statement of Purpose and Service Users Guide. The manager reported that no complaints have been received. The CSCI has not received any complaints. Policies are in place for the protection of vulnerable adults, with clear guidelines of actions to be taken. Staff complete training in protection issues. The manager understands her responsibilities in relation to protection of people who use the service. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 16 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, 27, 28 and 30 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to meet the needs of the people who live there. Bedrooms are single and people are encouraged to personalise their rooms. EVIDENCE: People who use the service have full access to a kitchen, dining area and lounge. Bedrooms are single and have been personalised to individuals taste. Sufficient bathrooms and toilets are provided. The laundry room is away from the kitchen. Appropriate policies and practices are in place for infection control. New flooring has been provided in bedrooms. People who use the service confirmed that they have everything they need in their bedrooms, that they have been able to personalise their rooms to their taste and that they like their rooms. All areas of the home were clean and tidy. 231 Stafford Road DS0000007214.V348782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the service are happy with the care they receive. Staff have good training opportunities. The recruitment process is good with systems in place to ensure appropriate checks are made. Regular staff meetings and supervision takes place. EVIDENCE: The published staff rota identified two members of staff on duty during the day with one member of staff awake and one asleep but on call at the home at night. The manager is available weekdays in addition to these hours. Some days more staff are on duty to support people who use the service to participate in community activities. Comments about the staff included ‘the staff are ok’, ‘staff help’ and ‘staff do as I ask’. The policies and practices for recruiting staff are in line with legislation. Staff files contain a copy of the application form, two written references, a Criminal Records Bureau check, a copy of the contract of employment, proof of the individuals identity and a recent photograph. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 18 The organisation has a training and development programme available to all staff. Staff have completed training in manual handling, medication administration, infection control, risk assessments, food hygiene, health and safety, epilepsy and values. The manager reported that staff are due to complete training in fire safety in mid September 2007. Five members of staff have completed NVQ to Level 2. One member of staff has NVQ to level 3 and one member of staff is in the process of doing NVQ to Level 3. Staff confirmed that they receive training and support to enable them to do their job. Records indicated that staff receive regular supervision from the manager. Staff receive an annual appraisal. 231 Stafford Road DS0000007214.V348782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager has the required experience and qualifications to run the home. Quality assurance systems are in place to seek people who use the service and other stakeholders opinions of the services provided and how they could be improved. Good health and safety policies and procedures are in place, with checks and records up to date. EVIDENCE: The manager has over ten years experience in similar services and has been at the home for four years. The manager demonstrated knowledge and understanding of the needs of people who use the services and managing staff. Staff meetings take place every month with records available. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 20 The organisation has quality assurance systems in place including a monthly visit to the home by a representative of the organisation. A copy of the report from this visit should be sent to the CSCI. The manager reported that questionnaires were sent to people who use the service last year, this should be done every year. House meetings have been held every month. It may be worth looking at the use of these house meetings and trying other ways to seek people who use the services opinions about the care and support they receive. One member of staff is responsible for completing a monthly health and safety check. Records were up to date and showed where repairs had been requested. The regular checks on the fire alarm system, portable electrical appliances, gas safety and hoists were up to date. The electrical supply system check indicated some areas which needed to be improved, records did not confirm that these issues had been addressed. 231 Stafford Road DS0000007214.V348782.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 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 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 X 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 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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. 1. 2. Refer to Standard YA6 YA42 Good Practice Recommendations The records from reviews should be on people’s files to ensure up to date information is available. Records should indicate that work has been completed after the electrical supply check in 2003. 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 231 Stafford Road DS0000007214.V348782.R01.S.doc Version 5.2 Page 24 - 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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