Inspection on 30/11/05 for 267 Hersham Road

This inspection was carried out on 30th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 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 01/08/05

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 Denise Debieux Announced Inspection 30th November 2005 10:00 Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hersham Road (267) Address 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ 01932 226125 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) The Regard Partnership Limited To be confirmed Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 20-65 years Services users shall all be in the category LD (Adults with learning disabilities). Two named persons may also have a physical disability. 1st August 2005 Date of last inspection 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) DS0000013470.V252364.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Ms Suzan Namusoke (Manager) was present as the representative for the establishment. A tour of the building took place with all of the six service users and three onduty staff being spoken with during the tour. The menus, care plans, staff rota, recruitment information, activity schedules and policies and procedures were all sampled. The inspector would like to thank the service users, manager and staff for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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): NONE EVIDENCE: These standards were fully assessed and met at the last inspection and were not covered on this occasion. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 and 9 The service users’ individual plans are clear and comprehensive and include details of needs and goals. They also incorporate known or indicated preferences and in depth risk assessments. EVIDENCE: Service users spoken with were complimentary regarding the care they receive at the home. One service user stated ‘They help us do things.’ Care plans inspected were comprehensive and set out actions which need to be taken by care staff to ensure that all aspects of the health and personal care needs of the service users are met. Daily recording was related to the care plans and showed that staff provide care and support to the service users in the way they prefer. The care plans also fully evidenced that staff enable service users to take responsible risks. These risks are assessed and included in each care plan with appropriate actions/training identified to reduce the level of risk. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 Meals are well-balanced and varied. EVIDENCE: The menu for the week of this inspection was seen to be varied and wellbalanced. The inspector was advised that service users plan their own meals, usually on a Sunday, with assistance and guidance from the staff where needed. The main, hot meal is in the evening. During the inspection the service users had a sandwich lunch of their choice, which they had helped to prepare. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. EVIDENCE: Service users spoken with confirmed that staff provide personal care and assistance, where needed, in the way they have indicated they prefer. This was seen to be clearly set out in their individual plans. The care plans sampled also provided evidence that service users’ healthcare needs are being met. Service users are all registered with a local GP and referrals to other health care professionals are obtained, as necessary, from the GP surgery. Staff were observed to always knock and ask permission to enter service users’ private rooms and all personal care was carried out behind closed doors. Assistance is provided to promote and maintain independence where appropriate. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 The policies and procedures in place to protect service users from harm or abuse need to be reviewed in line with the Surrey Multi-agency Procedure and the Department of Health ‘No Secrets’ guidelines. EVIDENCE: The home has a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and the manager advised the inspector that she has attended the local training course. However, the manager and deputy were not totally clear on the course of action to take should an allegation of abuse arise. The corporate policy does not, at present, refer to local procedures and requirements have been made. Service users told the inspector that they felt safe at the home and were comfortable and at ease with the staff that were on duty. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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 The location and layout of the home is suitable for it’s stated purpose. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: During this inspection two service users proudly showed the inspector around their home. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The service users showed the inspector their bedrooms and said how much they liked their own rooms, which were highly individualised and contained many personal mementos and possessions. The home has a communal sitting room and a separate dining area, which is also used for activities. At the previous inspection a requirement was made that suitable blinds be fitted in the conservatory. Since that inspection a decision has been made to remove the existing conservatory and replace it with a new one. This work is due to begin in January 2006. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 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): 32, 34 and 36 The home has a staff training programme which is designed to ensure that service users are supported by competent and qualified staff. Arrangements for staff recruitment are not satisfactory and are placing service users at possible risk of harm or abuse. EVIDENCE: The manager expressed a strong commitment to National Vocational Qualification (NVQ) training for the staff. The home have been working towards having 50 of their care workers qualified to NVQ level 2 in care or higher by 31st December 2005. At present two of the thirteen care workers have already achieved NVQ level 2 qualifications, four are currently undergoing the training and a further two are due to start the NVQ level 2 training in January 06. During the inspection two staff files were sampled. On their application forms there were unexplained gaps in employment and the members of staff had not given a full employment history (as required by the new Schedule 2 of the Care Homes Regulations 2001, introduced in July 2004). Both files had proof of identity and current photographs. In both cases the home had obtained Criminal Records Bureau certificates. Requirements and a recommendation have been made regarding staff recruitment. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 Page 15 The home has a yearly appraisal and supervision system in place. The inspector was advised that all staff receive a yearly appraisal and formal staff supervision is carried out at least six times a year. Records of formal supervision sessions were seen in the staff files inspected. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Service users benefit from the management approach at the home providing an open, positive and inclusive atmosphere. EVIDENCE: The manager has been working at the home since October 2004 and her application to be the registered manager is currently being processed by the CSCI Eashing office. She was the manager of another home for two years prior to October 2004, has achieved NVQ level 2 and 3 in care and has recently completed her Registered Manager’s Award and is awaiting her final certificate. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 Page 17 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 X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hersham Road (267) Score 3 X X X Standard No 37 38 39 40 41 42 43 Score X 3 X X X X X DS0000013470.V252364.R01.S.doc Version 5.0 Page 18 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. 1 Standard YA23 Regulation 13(6) Requirement The registered person must review the home’s policy on the prevention of abuse in line with the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. The registered person must ensure that all staff working at the home are aware of the Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. The registered person must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must ensure that staff files for all persons employed since 26th July 2004 contain all information and documents specified in paragraphs 1-9 of Schedule 2 of DS0000013470.V252364.R01.S.doc Timescale for action 30/01/06 2 YA23 13(6) 28/02/06 3 YA34 19(1)(b) 30/11/05 4 YA34 19(1)(b) 11/01/06 Hersham Road (267) Version 5.0 Page 19 The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) and be satisfied as to the appropriateness of the references obtained. 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 YA34 Good Practice Recommendations It is recommended that Regard Partnership Ltd review their employment application form to encompass the new requirements of Schedule 2 of the Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). E.G. request a full employment history instead of the past 10 years only; ask for reasons for leaving previous jobs; ask for gaps in employment to be explained; etc.. Hersham Road (267) DS0000013470.V252364.R01.S.doc Version 5.0 Page 20 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 © 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) DS0000013470.V252364.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!