CARE HOME ADULTS 18-65
Guildford Road (330a) 330a Guildford Road Bisley Woking Surrey GU24 9AD Lead Inspector
Susan McBriarty Unannounced Inspection 3rd October 2005 10:00 Guildford Road (330a) DS0000013490.V255959.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 (330a) DS0000013490.V255959.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 (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Guildford Road (330a) Address 330a Guildford Road Bisley Woking Surrey GU24 9AD 01483 489208 01999 999999 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 Ms Samantha Jayne Moth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Guildford Road (330a) DS0000013490.V255959.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: 35-65 YEARS One adult over the age of 65 years Date of last inspection 5th August 2005 Brief Description of the Service: 330a Guildford Road is located off the main road and approximately one (1) mile from the villages of Bisley and Knaphill. The home provides a living/dining room, kitchen, bathroom, shower room, toilets and five single bedrooms. There is a large rear garden, laid to lawn and ample car parking to the front of the house. The home is provided and managed by Care UK Limited. Guildford Road (330a) DS0000013490.V255959.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 inspection focussed on the requirements made at the inspection on the 5th August 2005 and the remaining standards requiring inspection. The residents of the home have limited verbal skills and some challenging behaviour. It is not possible to gain their views of the service without considerable planning and support. During the inspection two staff were spoken with and observations were made of the relationship between staff and residents. The Inspector sampled the medication administration records and a number of policies and procedures. What the service does well: What has improved since the last inspection? What they could do better:
A number of requirements and recommendations were made at the inspection on the 3rd October. The manager informed the Inspector that the homes policy and procedure regarding the protection of vulnerable adults had being revised, a copy of the revision was not available. It is required that the policy and procedure are in line with local guidelines.
Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 6 The previous requirement made at the inspection on the 5th August 2005 that all residents have a contract or statement of terms and conditions continues to meet with some difficulty. It is recommended that Care UK inform the CSCI of those problems in writing. Care UK undertakes a regular quality audit process with the home. The audit does not include residents, their representatives or others. It is recommended that Care UK review this process and seek to include residents and others in the quality audit process. The requirements and recommendations made are noted at the end of this report. 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 (330a) DS0000013490.V255959.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 Guildford Road (330a) DS0000013490.V255959.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): EVIDENCE: Standards 1,2,3,4 and 5 were assessed during the inspection of the 5th August 2005. Standard 6 does not apply. The home continues to seek contracts from the local authority for specified residents. The organisation has not control over the provision of these particular contracts. It is recommended that Care UK inform the Commission for Social Care in writing of the details of any difficulty in gaining such contracts. . Guildford Road (330a) DS0000013490.V255959.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: Standards 6,7,8,9 10 were assessed during the inspection of the 5th August 2005. The requirement made at the inspection that care plans and risk assessments are updated and signed wherever possible by the residents had been met. Guildford Road (330a) DS0000013490.V255959.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): EVIDENCE: Standards 11,12,13,14,15,16 and 17 were assessed during the inspection of the 5th August 2005. Guildford Road (330a) DS0000013490.V255959.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 Further work is required to ensure that the home follows their own policies and procedures with regard to the administration of medication and reducing recording errors made by staff. EVIDENCE: Standards 18,19 and 21 were assessed during the inspection of the 5th August 2005. The requirement made at the inspection on the 5th August remains ongoing. The home had taken into account the individual circumstances of each resident and is acting accordingly. It is expected that the requirement to record the wishes or best interests of each resident regarding terminal illness or death will be completed by the end of 2005. The Inspector sampled the storing of medication and medication administration records. Some minor errors were found with regard to the recording of administration of medication. For example the home had placed a timely request for prescriptions to be filled, the pharmacy was late delivering despite contact by the home; not all the records reflected in full the reason for late medication for one morning. It was also noted that not all the records for the administration of medication held photographs of specified residents. A
Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 12 requirement is made that the home reviews with staff the homes policies and procedures regarding the administration, storing and recording of medication. Guildford Road (330a) DS0000013490.V255959.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): 22,23 The home policies and procedures and the training of staff safeguard the residents; however further work is required to ensure that the homes protection of vulnerable adults policy is in line with local guidelines. EVIDENCE: No complaints had been received by the home and the complaints procedure meets The National Minimum Standards Younger Adults. The manager informed the Inspector that Care UK has revised the homes protection of vulnerable adults policy. A copy of the revision was not available to view. The policy sampled may be misleading to staff regarding the referral process. The manager was aware of the local guidelines and what action to take in the event of an allegation. A requirement is made to ensure that the policy and procedure for the protection of vulnerable adults meets the local guidelines. Guildford Road (330a) DS0000013490.V255959.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): 25,26 The Inspector is unable to make a judgement regarding the individual rooms of the residents as they were not seen. EVIDENCE: Standards 24,27,28,29 and 30 were assessed during the inspection of the 5th August 2005. The requirements made on the 5th August regarding the repairs and minor works had been met. A requirement was made on the 5th August 2005 to review the office area in the home to ensure the health and safety of staff. At the time of the inspection on the 3rd October 2005 Care UK had agreed that the manager move their office to a room over the garage, the deputy manager of the home taking over the small office in the home. A recommendation is made that Care UK ensure that both areas are assessed to ensure that any health and safety issues arising from working in those areas is assessed and any necessary action taken. The requirement that the propping open of fire doors be reviewed with the fire officer had been partly met. The home is reviewing options for the provision of
Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 15 safety devices that will stand up to the actions of the residents. At the time of the inspection on the 3rd October the doors were still being propped open using various items including a chair. The requirement remains in place with an extended date. The Inspector was unable to view individual residents rooms during the inspection. The CSCI will need to plan with the home this level of access to ensure the rooms meet The National Minimum Standards Younger Adults. Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: Standards 31,32,33,34,35 and 36 were assessed during the inspection of the 5th August 2005. The recommendation that supervision dates are planned and booked to ensure that the minimum six sessions per year are provided had been met. Guildford Road (330a) DS0000013490.V255959.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): 39 The home takes part in a quality audit process however further work is recommended to enable the residents of the home to take part in the audit. EVIDENCE: Standards 37,40,41 and 42 were assessed during the inspection of the 5th August 2005. The manager advised the Inspector that a copy of the quality audit undertaken had been sent to the CSCI following the inspection on the 5th August. This had not been received. A copy of the audit of a similar home Care UK was given to the CSCI at the time of the inspection on the 3rd October 2005. The audit undertaken by Care UK reviews the home against The National Minimum Standards, Younger Adults and how the home complies or otherwise. The audit does not take into account the views of the residents or others. The residents of the home are not able to fully verbalise their views and wishes. However observations made by the inspector at the time of the inspection confirm that staff members respond to appropriately to the
Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 18 residents needs. The organisation would need to consider options that might enable the residents’ views to be part of any future quality assurance audit. A recommendation is made that Care UK expand their quality audit process to include residents and others. The Insurance for the home was out of date at the time of the Inspection. The Inspector saw an email from the head office of Care UK informing the manager that they were aware that the certificate was out of date and that they were awaiting replacement from the insurance company. It is required that the home confirm to the CSCI, in writing, the delivery of the replacement certificates. The manager of the home meets regularly with their manager to discuss and monitor the finances and business plan of the home. The homes year runs from October to October and the business plans and budgets were in draft format. Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 19 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 3 2 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 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Guildford Road (330a) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X 3 3 X X X 2 DS0000013490.V255959.R01.S.doc Version 5.0 Page 20 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 20 Regulation 13(2) Requirement The registered person must review, with staff, the policies and procedures with regard to the recording, storage and administration of medication. The registered person must ensure that the homes policies and procedures for the protection of vulnerable adults meet the local guidelines. The registered person must inform the CSCI of the date the renewed insurance certificate arrives at the home or of continued delay of receipt. The registered person must inform the CSCI of the outcome of the fire risk assessment regarding the provision of door safety devices. Timescale of 31st August partly met. Timescale for action 20/10/05 2 23 13(6) 28/10/05 3 39 25(2)(e) 28/10/05 4 42 23(4)(c) (i)(iii) 25/11/05 Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard 5 23 39 Good Practice Recommendations It is recommended that Care UK inform the CSCI of any difficulties in gaining contracts for specified service users. It is strongly recommended that as part of the office move within the home that a health and safety audit is undertaken. It is recommended that Care UK include service users, their representatives and others in the quality audit process. Guildford Road (330a) DS0000013490.V255959.R01.S.doc Version 5.0 Page 22 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
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