Inspection on 17/05/05 for Dallimore House

This inspection was carried out on 17th May 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 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

Dallimore House 29/08/08

Dallimore House 01/08/07

Dallimore House 25/05/06

Dallimore House 15/11/05

Dallimore House 21/01/05

Dallimore House 12/08/04

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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 2a Guildford Road Chertsey Surrey KT16 0QA Lead Inspector Miss Marianne Barham Announced Inspection 17 May 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 2a Guildford Road Address Chertsey, Surrey. KT16 0QA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01932 568553 Welmede Housing Association Limited Mr Atmaran Beedasee CRH (PC) 12 Category(ies) of Learning Disability (LD) 12. registration, with number of places Physical Disability (PD) 4. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: It is a condition of Registration that of the twelve people accommodated in the home, up to four may be PD. Date of last inspection 21 January 2005 Brief Description of the Service: 2a Guildford Road is a detached property situated off of the main road and within walking distance of Chertsey town centre. The home is owned and managed by Welmede Housing Association, with the staff team employed by North East Surrey Primary Care Trust. The home provides accommodation and care for up to twelve people who have a learning disability, four of whom may also have a physical disability. The accommodation has communal facilities on each floor so that service users are able to live in smaller groups. There are currently six service users living on the first floor and four on the ground floor. The ground floor is wheelchair accessible throughout and has an assisted bath. Each floor has its own lounge, dining room, kitchen, laundry and toilet and bathing facilities. All bedrooms are single occupancy and none are en-suite. The first floor can be reached by by two sets of stairs, there is no passenger lift or stair lift. There is a well equipped sensory room on the first floor. The home has the use of two vehicles to access activities and local amenities and has limited parking to the side of the building. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out at 11.00am by Marianne Barham, lead inspector for the service. The inspection took place over a period of four hours and was the first inspection in the Commission for Social Care Inspection year April 2005 to March 2006. There was a calm atmosphere at the home and the service users appeared relaxed and well cared for. A total of six staff members and one service user were spoken with during this inspection. The registered manager for the home is currently suspended from duty. There are two acting managers overseeing the home, Cressida Rappella, who is the named responsible manager and will be referred to as the manager in this report, and Alistair Oglivy. Both were present during this inspection. What the service does well: What has improved since the last inspection? What they could do better: At present service users do not have meetings or any other way to make their views known and they do not take part in the daily running of the home, such as planning meals and daily routines. Ways in which this can be achieved were discussed with the manager and deputy. A requirement has been made to address this issue. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 6 The communal toilets and bathrooms do not have paper hand towels, posing a risk of cross infection. A requirement has been made to address this. A part of a worktop in the downstairs kitchen and a fitting for a handrail on the floor of the downstairs bathroom both require replacement or repair and requirements have been made to address these. Though the staff team have received training in the home on protecting vulnerable people, the correct procedures were not followed after a recent incident at the home. A recommendation has been made that all staff members attend the Surrey Multi-Agency training. It has been recommended that staff members record in the maintenance book when works have been carried out so that accurate records are kept. 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. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Service users needs are assessed and they are given sufficient information to make a choice about where they live. Service users and their families are able to visit the home prior to admission are given a written contract detailing terms and conditions of their residence in the home. EVIDENCE: The home has a comprehensive service users guide that is in a pictorial format to make it easier for service users to understand. The homes statement of purpose, complaints procedure, terms and conditions of residence and activities offered are contained in the guide. All service users are given a copy of the guide and are supported by staff members to understand it. The statement of terms and conditions is signed by, the service user, or a representative. Service users receive a full needs assessment prior to moving in to the home and are not admitted unless the manager is satisfied that the home can meet their needs. Welmede Housing Association has a moving in policy in place detailing procedures to follow when admitting service users to the home. Visits are encouraged and carried out as often as necessary prior to admission for service users and their families. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8 Service users are not given the opportunity to take an active role in the daily life at the home. EVIDENCE: The deputy manager stated that service users are encouraged to participate in their review meetings and to help with the housework. No service user meetings are held and there is no process in place to give service users the opportunity to participate in the daily running of the home. This was discussed with the manager and deputy and a requirement made to address this shortfall. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 Service users are able to take part in work and leisure activities that are appropriate to their age, peers, culture and leisure needs. EVIDENCE: Training and employment activities are based on the service users assessed needs. Each service user has a timetable of activities in place that includes accessing a day centre and also local amenities for leisure activities. The home has two vehicles to transport service users to the activities. The home also arranges outings to places of interest regularly, has in house activities such as bingo and sensory sessions and organises holidays both at home and abroad for service users, with the most recent being a holiday to the Canary Islands. One service user spoken with stated that they liked the activities and were happy living at the home. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Service users are supported according to their preferences and needs and their emotional and health needs are met by the home. EVIDENCE: Staff members at the home were observed to relate to service users in a caring and respectful way. They were seen to knock on doors prior to entry and to address service users in their preferred form, as detailed in the care plans. Staff members are trained at induction on issues of maintaining the privacy and dignity of service users while supporting them. All service users are registered with a local GP and have access to all health professionals as required. Annual health checks are carried out by the GP and service users are supported to have routine health screening such as a mammogram as appropriate. The home maintains an accident/incident record and notifications to CSCI have been received as appropriate. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users complaints are listened to and acted upon by the home and procedures are in place to protect service users from abuse, however they have not always been followed. EVIDENCE: The home has a complaints procedure in place and this is contained in the service users guide. It was pleasing to see that this has now been made available in a pictorial format as recommended at the last in section on 21st January 2005. The home has a copy of the Surrey Multi-Agency procedures for the protection of vulnerable adults and also a copy of Welmede Housing Association procedures on protection of vulnerable adults and whistle blowing. All staff members have received training in house on this issue, however the procedures were not followed after a recent incident at the home. A recommendation has been made that all staff receive the Surrey Multi-Agency training on protection of vulnerable adults. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27 and 30 The home is comfortable, clean and safe and service users bedrooms reflect their needs and interests. Toilets and bathrooms provide sufficient privacy, however adequate facilities for the prevention of cross infection is not provided. EVIDENCE: A requirement was made at the last inspection on 21st January 2005 that the homes maintenance programme be reviewed to be more flexible so that repairs could be carried out in the shortest time. It was pleasing to observe that a staff member has been named as responsible for reporting repairs to Welmede Housing Association and that repairs are being attended to more quickly, however the records have not been maintained accurately. A recommendation has been made to address this. The home is generally comfortably furnished, clean and well maintained. The worktop covering in the downstairs kitchen has a large piece missing which is unhygienic, this needs to be replaced or repaired. A requirement has been made to address this. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 14 All service users bedrooms were observed to be clean, tidy and personalised with their own belongings. Each is decorated according to the individuals taste and ornaments, pictures etc reflect their personal interests. The home has ample toilet and bathing facilities for the number of service users. The floor fixing for the handrail by the toilet in the downstairs parker bathroom is extremely rusty and unhygienic, and must be attended to. It was also observed that none of the communal toilets and bathrooms have paper hand towels. Requirements have been made to address these issues. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, and 33 Staff members are aware of their individual responsibilities and the service users supported by an effective staff team. EVIDENCE: All staff members have a job description outlining their role and responsibilities at the home. These have recently been reviewed as part of the NHS Agenda for Change process. The home has a stable staff team, many of whom have worked at the home for a number of years. Any shortfall in the number of staff members is covered by a bank work system. The home does not employ agency staff. Staff ratios to service users are agreed with the funding authority following assessment of individual needs. Staff team meetings are held regularly and comprehensive records of issues discussed are maintained. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 40 The home remains well run by a competent manager and the homes policies and procedures protect the best interests of the service users. EVIDENCE: The registered manager of the home is currently under suspension from duty. The home is being managed by two managers who are registered with CSCI at other homes managed by Welmede Housing Association. The named responsible manager for the home is Cressida Rappella, with Alistair Ogilvy assisting her. Both of these managers have many years experience and one or other is at the home each day. Despite the upset caused by the absence of the registered manager, morale in the staff team remains positive and staff members spoken with reported that they enjoyed working at the home and were happy with the management arrangements. The manager has ensured that continuity for the service users is maintained as far as possible during this time. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 17 The home has a comprehensive list of policies and procedures in place that staff members are made aware of at induction and then updated through staff team meetings. Each policy has a read sign form attached to ensure all staff read them. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 1 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 2 x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score 3 x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2a Guildford Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 x x x H58 H09 s13481 2a Guildford Road v218964 170505 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 8 Regulation 12 (3) Requirement Timescale for action 17/08/05 2. 27 13 (3) 3. 27 13 (3) 23 (2) (b) 4. 30 13 (3) 23 (2) (b) The registere person must implement a process that enables service users to participate in the daily running of the home, seeks their views and acts upon them. This must be recorded. The registered person must 17/06/05 ensure that paper hand towels and dispensers are placed in all communal toilets and bathrooms to reduce the risk of cross infection. The floor fixing for the hand rail 17/06/05 by the toilet in the downstairs bathroom must be replaced or the rust removed and made good. The registered person must 17/06/05 repair or replace the broken area of worktop cover in the downstairs kitchen. 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 Good Practice Recommendations H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 20 2a Guildford Road 1. 2. Standard 23 24 It is strongly recommended that all staff members attend the Surrey Multi-Agency training on the protection of vulnerable adults. It is recommended as good practice that when works have been carried out in the home that this is recorded in the maintenance record book. 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 2a Guildford Road H58 H09 s13481 2a Guildford Road v218964 170505 Stage 4 ann.doc Version 1.30 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. 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