Inspection on 24/01/06 for 27 Larchwood Close

This inspection was carried out on 24th January 2006.

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 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

27 Larchwood Close 10/07/07

27 Larchwood Close 05/10/06

27 Larchwood Close 30/08/05

27 Larchwood Close 05/01/05

27 Larchwood Close 10/06/04

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

CARE HOME ADULTS 18-65 Larchwood Close (27) 27 Larchwood Close Banstead Surrey SM7 1HE Lead Inspector Deavanand Ramdas Unannounced Inspection 24th January 2006 10:00 Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Larchwood Close (27) Address 27 Larchwood Close Banstead Surrey SM7 1HE 01737 370115 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.mencap.org.uk Royal Mencap Society Mrs Mary McCallion Care Home 7 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: SIX (6) AGED 35 YEARS - 65 YEARS, ONE (1) OVER 65 YEARS The home may accommodate 1 (One) resident with both a learning disability (LD) and a physical disability (PD) within the total number of residents accommodated. 30th August 2005 Date of last inspection Brief Description of the Service: Larchwood (27) is a large detached property located in a residential area in Banstead, Surrey and is registered with the Commission for Social Care Inspection as a care home providing personal care for six people with a learning disability. Accommodation is on two floors accessed by stairs and comprises of six single bedrooms, a lounge, dining area, kitchen, utility room, office, shower rooms and a bathroom. The home has a large garden to the rear of the property which is easily accessible and private parking is available to the front of the property. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection by one inspector carried out over a period of four hours. A partial tour of the premises took place, staff and service users were spoken, and documents and records were examined. The inspector would like to thank the manager, staff and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Medication management at the home must improve to ensure all medications prescribed by a doctor are recorded on service users medication record sheets to promote the health of service users. Corporate policies and procedures at the home must be updated to ensure staff have up to date information to safeguard the welfare of service users. The flooring in the utility room must be finished and the previous requirements made in respect of fire safety must be acted upon to promote the health and safety of staff and service users Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3&5 The homes statement of purpose and service user guide are good providing service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for assessing needs are adequate ensuring the aspirations and needs of service users are assessed. The systems for meeting needs are satisfactory and prospective service users know the home will meet their needs and aspirations. Service users are offered written contracts to safeguard their tenancy rights. EVIDENCE: The home had a statement of purpose which described the aims, objectives and philosophy of the home. The service user guide contained information about the facilities the home offered, and included details on contracts and the complaint policy. The information was clearly written, well presented and available to staff, service users and relatives. The home had a policy on needs assessment and a staff stated prospective service users would only be admitted to the home on the basis of a full assessment. The inspector sampled records and noted service users had care plans which reflected personal support, family contact, physical care and specific medical conditions which required specialist input from a practice nurse. Evidence indicated service users individual aspirations and needs were assessed prior to admission to the home. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 9 Staff working at the home have regular training and collectively have the skills to meet the needs of service users with specialist input being provided by health care professionals. The home offered contracts which were dated and signed by the provider and service user and specified the fees and room to be occupied by the service user. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 10 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): 10 Policies and procedures are adequate ensuring information about service users is handled appropriately. EVIDENCE: The home had a policy on confidentiality and staff have training in confidentiality which is reflected in the induction programme. Records were up to date, accurate and confidentially stored in a locked cabinet in the manager’s office. During discussions a member of staff stated “all information about service users is confidential”. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 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): 15,16&17 The systems for supporting service users are adequate ensuring service users maintain personal and family relationships. The daily routines are satisfactory ensuring service users rights are respected. Meals at the home are good offering variety and choice. EVIDENCE: The home supported service users to maintain family links and friendships and service users regularly visited their family at week-ends. During discussions a member of staff stated service users attended a local self-advocacy group which gave them the opportunity to meet people and make friends. The inspector noted two service users from the home were featured in an article in the local newspapers to mark the twenty-fifth anniversary of advocacy partners. Observations confirmed service users had unrestricted access to the home, staff addressed service users by their preferred names, and a support worker knocking on doors before entering service users bedrooms. The home had a menu plan which was displayed in the dining area and service users were involved in planning the menu and preparing meals. The menu was regularly discussed, reviewed and updated to take account of service Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 12 users choices and preferences, and during discussions a service user stated “my favourite food is fish pie with runner beans”. Mealtimes are relaxed, unrushed and flexible to meet the service users needs and one service user with a medical problem had her nutritional needs assessed and reviewed. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 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): 20 The management of medication needs to improve to promote the health of service users. EVIDENCE: The home had a policy on medications and a service level agreement with a local chemist which supplied medications weekly. The home had two locked metal cabinets to store medications and kept a record of medications received at the home and returned to the pharmacy. Medication record sheets had a recent photograph of the service user and were dated and signed by staff. Staff had training in medications which was accredited by the National Open College Network and the manager stated the service level agreement for supplying medications to the home will be reviewed to ensure staff have access to more training and information. The inspector noted some prescribed medications were not recorded on the medication record sheet and a requirement has been made to address this shortfall to promote the health of service users. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 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 The complaint process at the home is satisfactory with complaints information available to staff, service users and relatives. Policies and procedures are adequate ensuring service users are protected from abuse, neglect and harm. EVIDENCE: The home had a complaint procedure which contained information about the complaint process and was available to staff, service users and relatives. A member of staff stated the home kept a record of complaints which was sampled and the inspector noted a complaint was recorded on the 6/5/05 and management action was taken. Service users had copies of the complaints procedure in the service user guide for information. The home had an abuse prevention policy, an abuse procedure and a copy of the local authority (Surrey County Council) multi-agency procedures for the protection of vulnerable adult. Staff had training in the protection of vulnerable adults and a member of staff stated all allegations of abuse would be taken seriously and recorded. The inspector noted the corporate policy did not reflect the category of professional abuse and a recommendation has been made to address this shortfall to ensure prospective new staff have up to date information as part of the homes induction process. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 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, 29&30 The management of the premises is satisfactory ensuring the home is safe and comfortable for service users. Adaptations and equipment at the home are adequate and maximise the independence of service users. The arrangements for hygiene and control of infection need to improve to promote the safety of staff and service users. EVIDENCE: On the day of the inspection the home was clean, well presented and free from mal odour and the standard of décor was good. Furniture and fittings were of good quality and the home was safe and comfortable. The inspector noted service users sitting in the lounge reading and watching the news on television. The home had adaptations and equipment to meet the individually assessed needs of service users and the bathroom, showers and toilets were fitted with grab rails to promote the independence of service users. The home had a policy on infection control and observations confirmed staff practiced infection control measures through regular hand-washing, and gloves, aprons and hand-wash was available in the home. The home had a utility room and the walls and floor was in need of finishing to ensure it is impermeable to prevent the spread of infection. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 16 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): 35 There is a staff training and development programme ensuring service users needs are met by appropriately trained staff. EVIDENCE: The manager stated the organisation has a corporate training plan and a member of staff remarked he had completed an induction and foundation training programme which included mandatory training courses, policies and procedures, principles of care and safe working practices. The inspector noted the home had staff induction documents and the information it contained was linked to the aims of the home and service users individual care plans. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 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 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): EVIDENCE: The standards in this section were not assessed during this inspection. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 18 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 3 4 X 5 3 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 X 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X X X Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 19 Yes. 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 YA-24 Regulation Requirement Timescale for action 01/04/06 2 YA-20 3 YA-30 13(4a,c)23(2a) It was a requirement that a risk assessment must be completed to confirm that during the day it was better to have the doors open to allow residents free access and limit the danger of someone being hit by a door being opened in a hurry. If the assessment determines that this is the case the service must find an alternative to using wedges, such as magnetic door holds, linked to the fire system. This requirement was not met in the timescale given previously. 13(c) The registered person must ensure prescribed medications are recorded on the medication record sheet to promote the health of service users. 12(1)(a)13(3) The registered person must ensure the walls and floor in the utility room is appropriately finished to ensure it is readily cleanable to prevent the spread of DS0000013471.V276083.R01.S.doc 01/02/06 01/03/06 Larchwood Close (27) Version 5.1 Page 20 infection. 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 YA-23 Good Practice Recommendations The registered person shall consider updating the Abuse Prevention Policy to include the category of professional abuse which is reflected in the local authority (Surrey County Council) procedures for the protection of vulnerable adults. Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 Page 21 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 Larchwood Close (27) DS0000013471.V276083.R01.S.doc Version 5.1 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. 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