Inspection on 09/12/05 for 31 Hadlow 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 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

31 Hadlow Road 09/05/07

31 Hadlow Road 19/09/06

31 Hadlow Road 30/08/05

31 Hadlow Road 01/03/05

31 Hadlow Road 04/11/04

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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 31 Hadlow Road Tonbridge Kent TN9 1LF Lead Inspector Paul Stibbons Announced Inspection 9th December 2005 10:40 31 Hadlow Road DS0000023883.V261727.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 31 Hadlow Road DS0000023883.V261727.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. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 31 Hadlow Road Address Tonbridge Kent TN9 1LF 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) 01732 770834 The Avenues Trust Limited Mr Antony Edward Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: 31 Hadlow Road is registered to provide care and accommodation for five people who have learning disabilities. The Avenues Trust owns the home and Mr Anthony Smith is the Registered Manager. The home is located within walking distance of Tonbridge town centre with good access to local amenities and public transport systems. The property is a detached house with service user accommodation on two floors. In addition to service users’ single bedrooms, there is a small bathroom and toilet, a shower room and a separate toilet. There is a lounge, dining room and kitchen. Laundry facilities are located in an outbuilding adjacent to the house. There is also a large garden mainly laid to lawn and a patio area. The home has parking area for 4/6 cars. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory inspector Paul Stibbons conducted this announced inspection from 10.40 hrs until 13.40 hrs on the 9th December 2005. Those present during the inspection included the manager, deputy manager, two members of staff and three service users. The inspector took the opportunity to speak to all those present. The pre-inspection questionnaire, two comment cards from GPs and four comment cards from relatives were received by the CSCI prior to the inspection date. A tour of the building was undertaken and a variety of records were examined What the service does well: What has improved since the last inspection? Since the last inspection the home has re-designed the confidentiality policy into a pictorial format to enable service users to understand their rights. A stakeholder questionnaire is now sent out and the results published so that individuals can be confident their views are valued. A more detailed policy for the Control of Substances Hazardous to Health has been produced to protect service users and staff. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 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. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 Service users are offered the opportunity of a trial period and adequate information on which to base an informed choice before committing to a permanent placement in the home. EVIDENCE: The home has prepared a Statement of Purpose and service user guides to provide information about the home to potential service users. Guides viewed were in pictorial format and staff are able to communicate in Makaton to cater for service users with communication difficulties. There have been no new admissions to the home for some years. The manager stated that following a full assessment potential service users would be offered the opportunity to have short visits, weekend stays and a settling in period before committing themselves to a permanent stay. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 10 Individual plans reflect the service users’ changing needs and personal goals and their right to confidentiality is upheld. EVIDENCE: Person centred planning takes place between service users and their designated keyworker. Information gained and decisions made at these meetings forms the basis of individual support plans. Support plans viewed were comprehensive and following discussion with the manager it is recommended that a support file containing relevant daily routines would be less bulky to work from. The home manager is currently designing a confidentiality policy in pictorial format so that service users understand the procedures relating to the confidentiality of information. 31 Hadlow Road DS0000023883.V261727.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): 14, 15, 16 Service users engage in appropriate leisure activities and their rights and responsibilities are respected. They are supported in maintaining personal and family relationships. EVIDENCE: Activity charts viewed indicated a range of leisure opportunities that included music sessions, art classes, trips to public houses, the cinema, ten-pin bowling and swimming. Two service users have personal tuition for drums and guitar. Staff were observed treating service users with dignity and respect; asking permission to enter their rooms. They are encouraged and supported in helping with household chores. Service users have access to the kitchen to make drinks and snacks and were observed doing so. The manager discussed a plan to restrict access to service users whilst ovens are in use as there is a tendency to open oven doors without understanding the dangers. Service users will still be able to access drinks at these times via a serving hatch. All service users receive visits from their families and have access to telephone facilities. Four comment cards received back from relatives state that staff welcomed them at any time. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21 Service users are unable to retain and administer their own medication, they are supported by staff and protected by the home’s policies and procedures. The wishes of individuals in the event of death is known and recorded in their care plans. EVIDENCE: Policies and procedures for dealing with medication were seen to comply with The Royal Pharmaceutical Society of Great Britain guidelines and named staff have passed a competence based training programme. It was noted however, that signatures were missing for one shift on the recording charts and some medication was over 1 year old. A review of recording procedures must take place and old medication returned to the pharmacy. The manager has ascertained the wishes of service users and relatives in the event of illness and death and these are recorded in individual care plans. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users views are listened to and acted upon and they are protected from abuse by staff training and the home’s policies and procedures. EVIDENCE: Training records show that all staff receive training around adult protection issues with regular refresher courses. House meetings and a user-friendly complaints procedure, in pictorial and audio format, gives service users the opportunity to voice concerns. Where required the individuals keyworker will support them in expressing their views. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 Service users live in a homely, comfortable and safe environment with adequate personal and communal space. EVIDENCE: The home is currently undergoing internal re-decoration and there is a comfortable communal lounge and dining area that are well furnished in addition to service users personal rooms. Service users have access to a large garden and patio area where there is ample room for activities and social gatherings weather permitting. Currently there is not any requirement for specialised equipment. The kitchen was clean and tidy but there are broken tiles and seals around worktops that must be replaced to maintain hygienic conditions. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34, 35, 36 Service users are protected by the home’s robust recruitment procedures and a well trained and supervised staff team meet their individual and joint needs. EVIDENCE: The fitness of prospective employees is checked by the company’s Human Resources department. A checklist is held within the home and evidences the taking up of two references and a CRB check. Staff files contained job descriptions that detailed roles and responsibilities of individuals. Training files indicate a comprehensive training programme relevant to meeting the individual and joint needs of service users. Four staff hold NVQ 2/3, one has applied for NVQ 3 and another for NVQ 4. Supervision rosters indicate that the staff team is supported and supervised on a regular basis. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 15 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): 42, 43 Service users benefit from competent and accountable management and their health, safety and welfare is actively promoted. EVIDENCE: The registered manager has been in post for some time and has considerable experience of working with this service user group. The manager’s qualifications include the Registered Managers Award, Certificate in Management Studies and NVQ 3 in Care. The manager demonstrated an open approach to the running of the home and an enthusiasm for positive change. Staff spoken with and feedback from relative comment cards support this view. The manager is accountable to the Service manager who visits monthly to audit the service. Through support plans, risk-assessments and health and safety records viewed, it is evident that the health, safety and welfare of service users is promoted and protected. 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 16 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 x 3 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 Hadlow Road Score x x 2 3 Standard No 37 38 39 40 41 42 43 Score x x x x x 3 3 DS0000023883.V261727.R01.S.doc Version 5.0 Page 17 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 YA20 Regulation 13 (2) Requirement Medication over 1 year old must be returned to the pharmacy and a review of recording procedures to take place. Broken tiles and worktop seals must be replaced in the kitchen. Timescale for action 31/01/06 2 YA24 23 (2) (b) 10/03/06 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 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 31 Hadlow Road DS0000023883.V261727.R01.S.doc Version 5.0 Page 19 - 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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