Inspection on 09/12/05 for 29-29a Shrewsbury Road

This inspection was carried out on 9th December 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29-29a Shrewsbury Road 29/05/07

29-29a Shrewsbury Road 28/04/05

29-29a Shrewsbury Road 18/08/04

29-29a Shrewsbury Road 11/05/04

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

CARE HOME ADULTS 18-65 Shrewsbury Road (29/29a) 29/29a Shrewsbury Road Redhill Surrey RH1 6BH Lead Inspector Susan McBriarty Unannounced Inspection 8th December 2005 10:00 Shrewsbury Road (29/29a) DS0000013480.V271401.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 Shrewsbury Road (29/29a) DS0000013480.V271401.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. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shrewsbury Road (29/29a) Address 29/29a Shrewsbury Road Redhill Surrey RH1 6BH 01737 778572 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) Prospect Housing and Support Services Mr Jack Bacciarelli Care Home 16 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (12) of places Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 28th April 2005 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. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005-2006. Only two standards had not been assessed during the inspection of the 28th April 2005, these remaining standards being assessed on the 9th December 2005. The home provides for individuals aged between 45 years and 82 years it is recommended that for the future the home be assessed using appropriate standards from The National Minimum Standards for Older People and Younger Adults. During the inspection of the 9th December 2005 four staff and two residents were spoken with and a number of documents sampled. The documents sampled included risk assessments, contracts, holiday planning forms and recruitment documents. The inspection took place at Shrewsbury Road and Prospect Head Office in Redhill. The CSCI wish to thank the staff and residents of Shrewsbury Road, the service manager and Human resources Department of Prospect for their help with the inspection. What the service does well: 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. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 6 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 Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 7 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): Although none of the standards were fully assessed during the inspection of the 9th December 2005 it was noted that further work was required to ensure that the contracts provided made clear who might be responsible for payments of some services. This would help prospective residents to understand what payments are needed for particular services. EVIDENCE: These standards were assessed during the inspection of 28th April 2005. This inspection focused on the experience of the residents living at the home. This included the provision of a holiday and who might be responsible for payment. The contracts provided do not make clear how a holiday might be funded. The contract provided by the organisation is an assured short hold tenancy and the document does not contain all the information required in Standard 5 of The National Minimum Standards for Young People or Standard 2 of The National Minimum Standards for Older People. Both standards are noted as the home provides for people from both age ranges. The matter was discussed both with staff at the home and the Service Manager of the organisation. A requirement is made that the organisation review the present contracts and ensure that all the information required is provided. Assured short hold tenancies could not be located for two residents, local authority contracts were found within their personal files. The contracts did not Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 8 provide all the information required in the standards noted previously in this section of the report. Shrewsbury Road (29/29a) DS0000013480.V271401.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): EVIDENCE: These standards were assessed during the inspection of the 28th April 2005. Shrewsbury Road (29/29a) DS0000013480.V271401.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): Although none of the standards were fully assessed during the inspection of the 9th December 2005 it was noted that procedures were in place to assist staff to organise holidays and trips out with the residents and ensuring the residents were as safe as possible. EVIDENCE: These standards were assessed during the inspection of the 28th April 2005. A number of documents sampled showed that the home plan and book holidays and activities with the residents. For example members of staff document the preferred choice of the residents, the cost of the holiday including travel and meals. A risk assessment was then required and a sample was seen, the assessment provided basic details of the support needs of the specified person. Minutes of residents meetings were also seen; those sampled showed that some residents of the home were very vocal about their choices. The residents gave clear information regarding their preferred food choices and their views of the activities they had taken part in. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 11 The residents spoken with during the inspection felt the staff listened to them and two of the residents in particular to keen to talk about the home and their personal lives. Both stated that the home was very good and that they liked living there. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were assessed during the inspection of the 28th April 2005. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: These standards were assessed during the inspection of 28th April 2005. Although Standard 23 was not assessed during the inspection of the 9th December the CSCI sampled residents finances and found that the balances noted on the cash forms were correct, one was 2p over. Specified residents also had accounts with building societies or banks that held their savings. The member of staff spoken with regarding residents finances was very aware of the individual circumstances and the action to take to gain access to additional funds if required by the resident. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: These standards were assessed during the inspection of 28th April 2005. Although these standards were not assessed during the inspection of the 9th December 2005 the CSCI had received a copy of the homes Regulation 26 visit and note the content here. A Regulation 26 visit carried out by the organisation to ensure the home is meeting the standards required. The Regulation 26 document noted a number of minor works and or repairs required at the home. No requirement was made as the document shows that the organisation expected the work to be carried out within a reasonable timescale. The repairs needed included repairing drawers in chest of drawers or wardrobes. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 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 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): 34,35 The organisation had been working hard to ensure that Standard 34 could be met in full; it was not possible to fully assess the standard although the CSCI was assisted as far as far as possible. Training records were held at the home showing that members of staff had received training in specified areas of their work. EVIDENCE: The home had a procedure to ensure that the records held were open to inspection at all times, unfortunately due to circumstances beyond their control this was not possible on the 9th December 2005. The key to the secure personnel records could not be gained and the CSCI attended the head office to view the recruitment files and Criminal Record Bureau (CRB) checks. The head of the organisations Human Resources Department (HR) stated that all the necessary recruitment documents were copied and sent to the home for their records. It was not possible to confirm that the requirement made at the last inspection had been met. A member of staff at the home confirmed that photographs had been taken but could not confirm that they had been placed on the personnel files. The HR Department reported that digital photographs were being taken of all members of staff although they were not able to confirm that they had been placed on the personnel files at the home. A further requirement was made that the home confirms that photographs of members of staff were on file. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 16 The organisation was working hard to ensure that any CRB checks carried out prior to July 2004 were being updated. They were also in the process of ensuring that all CRB checks carried out were being recorded appropriately. This would ensure that a record of all members of staff, their disclosure number and date of issue would be readily available if required and that any future need to update would also be readily identified. Updated guidance had been received by the organisation from the CSCI and they were reviewing their policies and procedures to ensure that they are able to meet the revised guidance. All CRB checks currently held by the organisation were filed separately and were secure. A number of photocopies and transferred CRB checks were seen. A requirement was made that the organisation refer to the CRB guidance to ensure that portability and disposal issues in particular were reviewed and appropriate action taken to meet the guidelines. The CSCI were able to evidence the mandatory training provided to members of staff working at the home through sampling records held at the home. Records evidencing qualifying training were sampled at the head office. A requirement is made that the organisation confirm that a copy of all training records including qualifying training are available at the home and open to inspection. Standard 33 was not assessed during the inspection of the 9th December 2005. Information had been received by the CSCI on the 9th December 2005 regarding the staffing at the home from the organisation. The Regulation 26 report noted that the home had difficulty in providing a stable staff team from the organisations permanent staff team and the service manager had required particular action to be taken to ensure that an experienced person was on duty for each shift until the matter could be resolved. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 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: These standards were assessed during the inspection of the 28th April 2005. Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X 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 X X 2 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shrewsbury Road (29/29a) Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000013480.V271401.R01.S.doc Version 5.0 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 OP2YA5 Regulation 5(b)(c) Requirement The registered person must review the individual contracts to ensure they contain all the information required. The registered person must confirm that each service user has a written statement of terms and conditions/contract. The registered person must refer to the CRB guidelines regarding the storage and portability of CRB checks and confirm in writing to the CSCI how they intend to meet the guidelines. It is required that all staff files contain a personal photograph. Timescale of 28th May 2005 could not be confirmed. The registered person must confirm in writing to the CSCI that all training including qualifying training records are held by the home. Timescale for action 30/01/06 2 YA5OP2 5 30/12/05 3 YA34 19(4) 30/12/05 4 YA34OP37 17(2) 30/12/05 5 OP30YA35 18(1)(a) 30/12/05 Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shrewsbury Road (29/29a) DS0000013480.V271401.R01.S.doc Version 5.0 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. 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