Inspection on 28/04/05 for 29-29a Shrewsbury Road

This inspection was carried out on 28th April 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 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

29-29a Shrewsbury Road 29/05/07

29-29a Shrewsbury Road 09/12/05

29-29a Shrewsbury Road 18/08/04

29-29a Shrewsbury Road 11/05/04

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33 St John`s Church Road

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

CARE HOMES FOR OLDER PEOPLE 29/29a Shrewsbury Road. Redhill, Surrey. RH1 6BH Lead Inspector Mr P Benthom Announced Inspection 28 April 2005 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 Older People. 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. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 29/29a Shrewsbury Road Address 29/29a Shrewsbury Road, Redhill, Surrey. RH1 6BH 01737 778572 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) Prospect Housing Association Ltd. Mr Jack Bacciarelli CRH (PC) 16 Category(ies) of Learning disability over 65 years of age registration, with number (LD(E)) 12. of places Learning disability (LD) 16. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All service users shall be aged over 40 years. A maximum of 12 service users may be aged over 65 years. Date of last inspection 18 August 2004. Brief Description of the Service: 29/29a Shrewsbury Road is situated in a quiet residential area close to local amenities in Redhill. The service, which is operated by Prospect Housing Association, provides care and accommodation for up to 16 people with a learning disability. The home aims to provide a safe and homely environment that enables service users to develop to their maximum potential and where they are treated with dignity and respect. Service users are very much an integral part of the homes operation. The majority of service users are aged over 65 and all are male. Accommodation is arranged in two self-contained units, one at ground floor level and the other at first floor level. A stair lift is provided to assist access to the first floor unit. Each unit has a separate entrance and can accommodate up to eight residents. Each unit also has its own lounge and dining room, as well as kitchen and laundry facilities. The two units share a large garden at the rear, and off-street parking is available at the front and side of the property. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 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 has been registered for some considerable time and was present for the inspection. The company area manager was also present for the inspection. Two members of staff were on duty in each unit and seven of the Service Users were spoken with. A tour of the premises took place and care, training and Health and Safety records were inspected. The home provided a high level of personalised support to service users. What the service does well: What has improved since the last inspection? The manager and staff have made real progress in the improvement of the physical environment for the Service Users. All areas of the home have been decorated and much of the furniture has been replaced. The result is a bright spacious home with tasteful and well-chosen colour schemes and furnishings. Service Users have been involved totally in the choosing of the new décor and furniture. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5 and 6 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: All prospective Service Users are invited to visit and live within the home on a trial basis. Service Users Tenancy agreements clearly set out the rights and responsibilities of the Service Users including their legal rights, and these agreements also discussed the responsibilities of the service toward the Service User. The home has produced a comprehensive Statement of Purpose and Service Users Guide. The home manager carries out assessments of prospective service users. Overall care plans were very well documented. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 9 The organisation’s policy on transitional arrangements and admission process is detailed in the Statement of Purpose and Service Users Guide. For example, prospective residents are invited to visit the home and to have a few over night stays prior to moving into the home. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The systems for the administration of medication are good and there are positive links with local GP and district nursing services. EVIDENCE: Decision-making is very much an integral part of life in the home and service users make all decisions about how they wish to use their occupational and leisure time. There was evidence that Service Users participate as much as possible in the day-to-day running of the home. The staff on duty said that Service Users are actively encouraged to make choices about their everyday lives in terms of where they go for leisure and educational pursuits and the type of food they wish to eat. Staff were noted to be aware of the need for the utmost confidentially in the management of Service Users confidential information and all personal information such as Care Plans and daily contact records are securely held in the home’s office. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Links with the local community are good and serve to enrich Service Users lives. EVIDENCE: The staff were seen to be encouraging Service users to make full advantage of all local amenities and facilities and Service Users seen on the day of the inspection were pleased to speak freely of the type of activities they become involved in. There was evidence on the day of the inspection were very much involved in pursuing outside interests. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 12 The home is well established in the local community and Service Users have a positive relationship with their neighbours. The home is located near to Redhill, Reigate and Crawley, and as such has good access to all leisure and educational activities. The menu is operated on a four-week rota and is compiled in consultation with Service Users. Service Users all reported positively about the meals. They were consulted at the beginning of the day about what they would like to have from the menu. The menu on the day of inspection was found to be wholesome and nutritious. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints system that is made available to all Service Users and staff. EVIDENCE: The home has developed its complaints procedure to incorporate details of the Commission for Social Care Inspection. The homes policies and procedures include a protection of vulnerable adults policy and a whistle blowing policy. The protection of Vulnerable Adults forms part of the staff induction programme and the staff-training file contained details of all up to date training. The complaints procedure was found to be clear and easy to read. All Service Users are provided with details of the company’s complaints procedure. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The home provides a comfortable and homely environment for the Service Users. EVIDENCE: All bedrooms were seen to have personal items and furniture that reflected Service Users personal choices. There are also sufficient toilet and bathroom facilities in this service to meet the needs of Service Users. There are good communal spaces provided for Service Users. There is a programme of refurbishment in place and furniture in communal areas is to be replaced with the next financial year. On the day of the inspection the Service Users were observed to be using all of these areas and the members of staff present were seen to be interacting appropriately with the Service Users in all areas of the home. Currently there are no environmental adaptations necessary as the current layout of the building meets the need of the Service User group. The home was clean and tidy and control of odour was good. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The staff team are committed to providing a high standard of care to the Service Users in this home. EVIDENCE: There is a very 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. The Home is committed to a rolling programme of NVQ training for all staff. Staffing levels comply with National Minimum Standards. There was evidence that a robust recruitment process had been followed and that it met the National Minimum Standards for protection of Service Users. There are arrangements to carry out CRB checks and two written references are required for all staff. All staff have completed induction and foundation training. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 The 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. EVIDENCE: The home’s manager/proprietor is experienced, and capable of running the home. He has attained NVQ Level 4 and the Registered Managers Award. He also has the Certificate in Management Studies and is an NVQ Assessor. The management of the home was observed to be open and inclusive. There was a positive, friendly and relaxed atmosphere. Service Users spoken with stated that they are content with the service provided. Service Users were observed to be settled and happy in their environment. There is a genuine commitment by the proprietor and the manager to regular 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 17 and updated training for all staff. Supervision records were seen indicating that a good supervision is in place. Similarly there is a thorough induction programme. The home has comprehensive employment policies. Records required for the protection of service users were well maintained, upto-date and accurate. The records of service users are secured in a lockable cupboard. There is a positive approach to health and safety in the home. Staff receive mandatory health and safety training as part of their induction. The provider organisation conducts an annual health and safety audit, to ensure compliance with current legislation. There is a comprehensive file with records of systems and equipment serviced or requiring service. There is a three monthly fire systems audit. Freezer and refrigerator temperatures are checked daily and records maintained. There were no identifiable Health and Safety issues apparent during this Inspection, and Safety Checks on equipment and Services such as Gas and Electricity are regularly undertaken. 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 N/A N/A 3 3 3 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 19 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 OP37.3 Regulation 17(2) Requirement It is required that all staff files contain a personal photograph. Timescale for action 28/5/05 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 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 Page 20 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 29/29a Shrewsbury Road. H58 H09 s13480 29 Shrewsbury Road v212377 280405 Stage 4 ann.doc Version 1.30 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!