Inspection on 01/08/05 for 267 Hersham Road

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

267 Hersham Road 25/07/07

267 Hersham Road 04/05/06

267 Hersham Road 30/11/05

267 Hersham Road 29/11/04

267 Hersham Road 15/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hersham Road (267) 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ Lead Inspector Peter Benthom Unannounced 1 August 2005 09:00am st 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 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 Stationary 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. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hersham Road (267) Address 267 Hersham Road, Walton-on-Thames, Surrey, KT12 5PZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01932 226125 The Regard Partnership Ltd, Unit 1, Princeton Mews, 167-169 London Road, Kingston-UponThames, Surrey, KT2 6PT To be confirmed Care Home (CRH) 6 Category(ies) of Learning disability (LD), 6 registration, with number Physical disability (PD), 2 of places Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be: 20-65 years 2 Services users shall all be in the category LD (Adults with learning disabilities). Two named persons may also have a physical disability. Date of last inspection 29 November 2004 Brief Description of the Service: 267 Hersham Road is a care home providing residential care for up to six residents with mild to moderate learning disabilities, two of whom may also have a physical disability. The home is detached and is situated in a residential area a short distance from Walton on Thames town centre and its facilities. The bedrooms are situated on two floors, two bedrooms are on the ground floor and four bedrooms are on the first floor. The bedrooms are personalised and homely. The garden is well maintained and safe for the service users to enjoy. Currently there are three male and three female service users living in the home. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the first of the year 2005/6 and was conducted by an inspector from CSCI. The manager is about to be registered. Three members of staff were on duty and four of the six Service Users in the home were spoken with. One service user in particular participated in some of the inspection process and was very complimentary about the manager and staff of the home. A tour of the premises took place and care, training and Health and Safety records were inspected. The home provided a high level of personal support to service users. Service users’ health needs were well met. Senior staff are trained in the administration of medication. The home has a thorough complaints procedure. The home has a positive and supportive relationship with the local surgery. Senior staff are trained in the administration of medication. There is a commitment from the proprietors and manager to provide staff with continual training and development. Staff and service users were spoken with and observation of practice was made. The CSCI would like to thank staff and service users for their hospitality throughout the inspection process. What the service does well: The home provided a high level of individualised support to service users. This was a commendable part of the home’s operation. The menus provided were appetising and well presented using fresh foods where possible. Links with service users friends and family were well developed and maintained by the operation of the home. Service users’ health needs were well met. The home has a thorough complaints procedure. There have been no complaints received either by the service or by the CSCI in relation to this service. The home is well maintained and furnished to high standard. It offers spacious and well-equipped accommodation to its service users. There is a commitment from the organisation to provide staff with continual training and development. The environment is modern, tastefully decorated and furnished to a homely and comfortable standard. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 6 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. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 standard(s) 1, 2,3, 4 and 5 Service users are admitted only following a full assessment undertaken by the proprietor who was able to demonstrate the homes capacity to meet the assessed needs. Adequate information was available for prospective service users, trial visits accommodated and contracts were in place. EVIDENCE: A copy of the statement of terms and conditions was sampled. Each service user was issued with a contract and a copy was observed in each service user personal file. There was evidence of a full comprehensive assessment procedure that was carried out by the manager of the home prior to admission. Service users and their families/representatives and relevant professionals are involved in the assessment process. Staff individually and collectively had the required level of skill and experience to deliver services and care in accordance with the home’s statement of purpose. As part of the assessment staff explored specialist needs and needs specific to minority and ethnic communities where applicable. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 standard(s) 6, 7, 8, 9 and10 The systems for Service User consultation that are in place provide evidence of Service Users views being accurately reflected as much as is realistically possible. Individual care plans were in place for all service users. EVIDENCE: Care plans were detailed in content and reviews were up to date. There was evidence that personal information is stored securely in line with Data Protection legislation. Evidence was found that Service Users are involved in realistic day-to-day participation in the running of the home and are given the opportunity to be involved in activities. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 and 17 Links with the local community are reasonably good and provide Service Users with opportunities to experience varied activities. Appropriate arrangements were in place for meal provision. EVIDENCE: A varied fulfilling daily activity programme for each Service User was seen as part of the inspection process. Service Users make full use local day services and are encouraged to use local facilities. Supported by members of staff they go shopping for their toiletries, clothing and footwear. All outings are subject to risk-assessments. The acting manager stated that the home maintains close relationships with service users’ as much as possible. The menus were examined and found to provide good varied, wholesome and nutritious food, with attention given to various likes and dislikes. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 standard(s) 18, 19, 20 and 21 The personal and healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. Medication arrangements were satisfactory. EVIDENCE: There was evidence that service users are supported by staff in a way that maintains their privacy and dignity. Individuals are encouraged to do what they can for themselves. There is attention to healthcare needs of service users living in the home. There is a policy in place to attend to the needs of service users in the latter stages of their life, should they still be at the home when this occurs. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 standard(s) 22 and 23 The home has a satisfactory complaints system that is made available to all Service Users and staff. Appropriate arrangements including policies and staff training were in place in respect of adult protection. EVIDENCE: The complaint procedure was compliant with statutory requirements. Complaint forms were available for recording complaints. An additional ‘speak up’ form in Makaton is in place for service users. Records demonstrated there had been no formal complaint received by the home or the regulator within the last twelve months. Service Users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. Up to date training in the Protection of Vulnerable Adults is in place and is part of the company’s ongoing commitment to staff training. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The home had a spacious communal sitting room and a separate dining room, which was also used for activities. Specialist bathing facilities and additional toilets were provided suitable to meet the needs of the service users and in close proximity to communal areas and bedrooms. All rooms were bright and adequately ventilated with the exception of the conservatory/dining room, which was found to be hot and uncomfortable to sit in. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 14 It is required that adequate blinds are fitted to provide shade from the sun and therefore allow the area to be used more freely at all times. Please see requirements on Page 20. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The staff had a good understanding of Service Users need. This was evident from the positive relationships that have been formed between staff and Service Users. Staff are aware of all aspects of protection of vulnerable people and appropriate up to date training is in place. EVIDENCE: The Home has a policy whereby all gaps in the staff rota are met by existing staff. All staff have completed induction and foundation training and there is a good training package for all staff leading to eventual NVQ training. The acting manager must be very highly commended for her commitment to training for all staff. The training programme follows the guidelines of the National Occupation Standards and each member of staff has an individual training and development plan. Training records were examined as part of the inspection process and were found to be up to date and detailed providing evidence of appropriate training being afforded to all staff at all levels. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 16 There is low staff turnover in this Home and there are appropriate training opportunities in place for all staff, and a commitment from the organisation to provide staff with a full and detailed training programme. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40 , 41, 42 and 43 The acting manager is supported by staff in providing clear and consistent leadership in the home with all staff illustrating an awareness of their roles and responsibilities. Good supervision arrangements are in place and all service users and staff are protected by the home’s record keeping and health and safety policies. EVIDENCE: Information from service users and staff confirmed that the management style in the home was open and that registered the providers are approachable at all times. The acting manager’s application for registration is in progress and she is working towards completion of the Registered Managers Award. Meetings were held for both staff and service users; all were encouraged to contribute to the development of the home. Supervision notes were not seen as part of the inspection process. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 18 Records required for the protection of service users and sampled on the day of the inspection were well maintained, accurate, and up to date. The staff-training programme includes training in first aid, manual handling, infection control, fire safety, health and safety and basic food hygiene. Systems were in place to safeguard the health and safety and welfare of the service users. Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hersham Road (267) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 20 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 YA24 Regulation 23(2)(p) Requirement It is required that blinds are fitted to the roof of the conservatory in order to priovide adequate shade and protection to service users. It is required that all information contained in Schedule 2 of the Care Home Regulations 2001 is contained on all staff personnel files Timescale for action 30 /9/05 2. YA41 19 Schedule 2 31 August 2005 3. 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 Good Practice Recommendations Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hersham Road (267) H09 H58 S13470 267 Hersham Road V235519 010805 Stage 4 unn.doc Version 1.40 Page 22 - 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!