Inspection on 03/10/05 for 330 Guildford Road

This inspection was carried out on 3rd October 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

330 Guildford Road 22/06/06

330 Guildford Road 14/07/05

330 Guildford Road 04/11/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Guildford Road (330) 330 Guildford Road Bisley Woking Surrey GU24 9AD Lead Inspector Susan McBriarty Unannounced Inspection 3rd October 2005 10:00 Guildford Road (330) DS0000013489.V255958.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 Guildford Road (330) DS0000013489.V255958.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. Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Guildford Road (330) Address 330 Guildford Road Bisley Woking Surrey GU24 9AD 01483 489208 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) Care UK Community Partnerships Limited Mrs Gillian Kathryn O`Hara Care Home 6 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (2) of places Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 39 – 65 YEARS & 2 MAY BE OVER 65 YEARS The number of persons for whom residential accommodation with both board and personal care is provided at any one time shall not exceed SIX (6). 14th July 2005 Date of last inspection Brief Description of the Service: The home is a large detached property, located off a main road and approximately 1 mile from the village of Bisley. The property is registered to accommodate up to 6 people with learning disabilities. The home has a living room, with a separate kitchen and dining room. Each resident has a single room. It has a large front and back garden, with some parking available. The home also has transport available for Service Users. Guildford Road (330) DS0000013489.V255958.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. The Inspector spoke with two residents and two staff excluding the manager, during the inspection. A number of records were sampled during the inspection including staff personnel files, resident files, policies and procedures, draft finance and business plans and the staff rota for October 2005. The residents of the home have complex needs and were not able to take a full part in the inspection process. Observations were made by the Inspector and where possible have been included in the report. 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. Guildford Road (330) DS0000013489.V255958.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 Guildford Road (330) DS0000013489.V255958.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): 1,3,4,5 Information about the home was available for new residents and they would be able to visit the home before making a choice about living there. There was evidence of assessments being undertaken prior to a new service user moving into the home. Contracts were not in place for service users. EVIDENCE: The home had a statement of purpose and service user guide that would help prospective residents and their representatives to make a decision about moving into the home. Once a move has been agreed an individual plan is agreed to assist the new resident to move to the home. Records sampled by the Inspector evidenced that assessments were undertaken on prospective residents prior to their move to the home. Contracts with the local authority may take some time to be completed and some residents were still waiting for their contract to arrive. It is recommended that where there has been a considerable delay in providing residents with a contract the home inform the CSCI. The Inspector spoke briefly with a new resident regarding their move to the home, however it was not possible to gain a clear picture of their view of the move. Observations by the Inspector noted the specified person making some decisions about where they wished to be in the home including where they wanted to eat their breakfast. Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 8 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): 7,8, 10 The residents abilities to make decisions regarding their preferred options is limited due to their learning disability. EVIDENCE: The Inspector observed staff and residents during the inspection and observed decisions being made about food choices, where they wished to sit and eat and access to some activities. Decisions regarding access to advocacy, dealing with individual finances and the development of policies and procedures are taken by the staff team in consultation with others, where possible, or the organisation (Care UK). Information about the residents was held securely with appropriate access to care plans and risk assessments by staff members. Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 9 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): 11,14,17 The residents were able to take part in activities and were aware of what they would be doing during the course of the day. The people living in the home were provided with a varied and nutritious diet. EVIDENCE: One specified person was going out and was able to indicate to the Inspector where they were going for the day and who with. The home had recently updated the information regarding which activities particular residents took part in each, the information included transport needs. Specialist services were available to those residents who required additional interventions. The information from the specialist services also assisted the staff team to ensure that care and support was provided in an appropriate way. The Inspector sampled the homes menus and the records held regarding what food was eaten by whom. The menus and records evidenced that there are times when the residents choose not to eat what had been planned and an alternative had been provided. The menus and records seen evidenced a Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 10 varied and nutritious diet. As noted previously in this report the residents can choose where they wish to eat. Guildford Road (330) DS0000013489.V255958.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): 19 The home ensures the health care needs of residents are met. EVIDENCE: Those resident files sampled by the Inspector evidenced records of access to services such as the dentist and optician. For some residents access to additional specialist health services were recorded. The residents require staff support to attend appointments and given the level of the assessed needs of the residents’ staff would be present during the majority of appointments with health professionals. Guildford Road (330) DS0000013489.V255958.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): These standards were assessed during the inspection on the 14th July 2005. EVIDENCE: Guildford Road (330) DS0000013489.V255958.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): These standards were assessed during the inspection on the 14th July 2005. EVIDENCE: Guildford Road (330) DS0000013489.V255958.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): 31,32,33,36 The home ensures that staff training is planned and implemented. Job descriptions for staff members were available for inspection. EVIDENCE: The Inspector sampled some of the staff personnel files, not all contained the required job descriptions. However, the job descriptions were held elsewhere within the home and were waiting to be filed appropriately. The manager informed the Inspector that all staff members had been issues with a copy of the General Social Care Council code of conduct for social care staff. A number of the organisations policies and procedures were being reviewed and the home was awaiting replacements to their current folder. Although the standard regarding the protection of vulnerable adults was not assessed during the inspection it was noted that it required revising to meet the local guidelines. A requirement was made to ensure that the revised version of the policy and procedure met the local guidelines. The records sampled by the Inspector evidenced that the home seeks appropriate specialist health support and have a good knowledge of the residents assessed needs. Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 15 At the time of the inspection 5 of the 10 permanent staff members held a National Vocational Qualification at either Level two or three. The Inspector was provided with a copy of the staff rota for October 2005. The rota shows that three staff excluding the manager are on duty each morning and afternoon with one member of staff covering a shift of 9am to 4.30pm. One member of staff is present overnight. Further work is required to ensure that the home meet the supervision target of six sessions per year. The Inspector observed that members of the staff felt able to approach the manager with any queries during the course of the inspection. Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 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 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): 37,38,43 The home had an open and inclusive approach where staff and service users were listened to. Staff training information was recorded in full. The home has an annual budget and business plan. EVIDENCE: The manager is social work qualified and has completed the registered managers award. The manager was able to evidence current work regarding the setting of the homes annual budget and business plan. The manager works with a senior colleague to ensure a clear and understandable framework for the home to work within. The current certificate of insurance is out of date. The Inspector was shown the copy of an email from the home’s head office that showed they were aware of this shortfall and that the renewed insurance certificate was expected from the insurance company. It is required that the home confirm with the CSCI when the updated certificate has been received. Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 17 The home has an open and inclusive atmosphere with both staff and residents feeling able to approach the manager with day-to-day issues. The Inspector was provided with a copy of the last quality audit undertaken on the home. The audit focuses on how well the home meets The National Minimum Standards, Young Adults. There was no evidence that residents, their representatives or others were included in the process. It was required at the last inspection that the home develop questionnaires for relatives for quality assurance purposes, this had not been met. Standard 42 was assessed during the inspection of the 14th July 2005, however it was noted during this inspection staff did not consistently keep the homes fridge and freezer records. There were a significant number of gaps evidenced within the records. A requirement is made that the home ensure that records are made consistently sand inline with the homes policies and procedures. Guildford Road (330) DS0000013489.V255958.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 3 X 3 3 2 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 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 3 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Guildford Road (330) Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X X 2 DS0000013489.V255958.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 23 Regulation 13(6) Requirement The registered person must ensure that the policy and procedure for the protection of vulnerable is revised in line with local guidelines. The registered person must review the quality audit process in order to include the relatives of service users. Timescale of 10/09/05 not met. The registered person must ensure that records for fridge and freezer temperatures are kept in line with the homes policies and procedures. The registered person must inform the CSCI of the date when the renewed certificate of insurance is received or of further delays in receipt. Timescale for action 28/10/05 2 39 24(3) 30/11/05 3 43 13(4)(c ) 01/11/05 4 43 25(2)(c) 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000013489.V255958.R01.S.doc Version 5.0 Page 20 Guildford Road (330) 1 2 Standard 5 36 It is recommended that the registered person inform the CSCI of those specified service users where the local authority has not provided a contract. It is strongly recommended that the home plan supervision sessions with staff in order to meet the standard of six supervision sessions per year. Guildford Road (330) DS0000013489.V255958.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. Extracts may not be used or reproduced without the express permission of CSCI Guildford Road (330) DS0000013489.V255958.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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