Inspection on 05/04/05 for 40 Fir Tree Road

This inspection was carried out on 5th April 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 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

40 Fir Tree Road 26/08/08

40 Fir Tree Road 16/07/07

40 Fir Tree Road 16/10/06

40 Fir Tree Road 01/11/05

40 Fir Tree Road 20/09/04

40 Fir Tree Road 24/05/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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 HOMES FOR OLDER PEOPLE 40 FIR TREE ROAD BANSTEAD SURREY SM7 1NG Lead Inspector Peter Benthom Announced Inspection 05 April 2005 10:00 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 Older People. 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. 40 FIR TREE ROAD Version 1.10 Page 3 SERVICE INFORMATION Name of service 40 FIR TREE ROAD Address 40 FIR TREE ROAD, BANSTEAD, SURREY. SM7 1NG 01737 379242 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) COMMUNITY INTEGRATED CARE MRS JUDITH CONTEH CRH (PC) 8 Category(ies) of LD (E) 5, registration, with number PD(E) 4, of places LD 3, PD 2. 40 FIR TREE ROAD Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 24 May 2005 Brief Description of the Service: The home is registered as a care home only within the service user category: Learning disability (LD) and Learning disability over 65 years of age. The home is registered to accommodate a maximum of seven Service Users.Community Integrated Care manages the home.It is a large detached house with extensive grounds to the front and rear and is situated on a busy main road, near to Banstead centre.40 Fir Tree Road 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 despite their profound disabilities.The home provides a good standard of accommodation to its Service Users. 40 FIR TREE ROAD Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the first of the year 2005/6 and was conducted by two inspectors from CSCI. The manager is newly registered and was not present for the inspection. The inspection was competently carried out by a senior support worker acting in the manager’s absence. Four staff were on duty and four of the seven Service Users were spoken with. A tour of the recently refurbished and redecorated premises took place and care records were inspected. What the service does well: What has improved since the last inspection? What they could do better: Recruitment has been largely successful; however there has been some difficulty in recruiting staff with sufficient knowledge of English. This has proved problematic as none of the Service Users are able to communicate verbally and as such non-English speaking staff are not able to attend fully to their needs. Great care must be taken therefore to recruit staff that are willing to undertake learning English if this is not their first language. 40 FIR TREE ROAD Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 40 FIR TREE ROAD Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection 40 FIR TREE ROAD Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 Thorough assessments are carried out on all prospective Service Users prior to their admission to the home. EVIDENCE: The home had an updated statement of purpose, which accurately depicted the services provided by the home. The service user plans in place were comprehensive and have been updated and reviewed since the registered manager has been in post. A prospective Service User has been referred for care at the home and the manager and her staff team are in the process of completing a full assessment of his needs prior to his admission. There has been some pressure from the referring agency to admit the new Service User without delay, however the manager is clear that a rapid admission would be inappropriate and conflicting with the policies and procedures of the home and of the organisation. 40 FIR TREE ROAD Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The systems in place for Service User consultation are good and access to support from health care agencies is clearly evidenced. The systems for administration of medication are good with clear arrangements in place to ensure that Service Users medication needs are being met. EVIDENCE: Service users’ health needs were well met and medication administration was accomplished satisfactorily. The service plans in place were comprehensive and are reviewed on a monthly basis to ensure that they accurately depict service users’ needs. Daily notes were informative and included details about what activities the service user had participated in and their mental status. Staff stated that service users are involved as much as possible with the care plan development and reviews. There is evidence that Service Users’ optical, dental and chiropody needs are met and confirmed in the diary and other records. Where appropriate, occupational therapists, dieticians and speech therapists would be involved in 40 FIR TREE ROAD Version 1.10 Page 10 Service Users’ care. The records showed assessed medical needs were followed up properly and notes taken of the care given. None of the service users are able to self-administer their own medication and suitably trained and staff dispense all medication. All staff are trained in the administration of medication. 40 FIR TREE ROAD Version 1.10 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Links with the community and with relatives and friends are good and appetising and nutritious food is provided at all times. EVIDENCE: The service assists service users with transport in order to access the local community. Service Users were able to have visitors at any reasonable time in private. Communal areas are utilised by service users to entertain their visitors. Alternatively service users can entertain in their own bedrooms in private, in the quiet lounge areas or in the garden areas (weather permitting). Service users in this service are unable to manage their own financial affairs, as a consequence these are usually managed by relatives and advocates which was seen to be the most appropriate process. Mealtimes were observed to be satisfactory and unhurried occasions. During the inspection service users were observed enjoying their midday meal, which was seen to be of high quality and presentation. There is also a choice of menu at lunchtime and suppertime and both meals are sufficient in quantity and appearance. 40 FIR TREE ROAD Version 1.10 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Service Users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: There have been no complaints since the last inspection. The home has a complaints procedure in place in line with Community Integrated Care policies and procedures. All Service users have been supplied with a copy in pictorial format. The service has an adult abuse policy in place. Staff had received training in the protection of vulnerable adults in February 2005. The Local Authority multi-agency procedures for protecting vulnerable adults were in place at the service. 40 FIR TREE ROAD Version 1.10 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20,21, 22, 23, 24, 25 and 26 The environment is well maintained and benefits from recent extensive refurbishment. Service Users are provided with a high standard of living accommodation. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. Standards of cleanliness and hygiene were high throughout the home and no malodours were evident. The home’s communal areas are spacious and are decorated and furnished to a very good standard. No safety hazards were evident within the communal and private space areas. Toilet and bathing facilities were of a very good standard and afforded adequate privacy for the service users. Service Users bedrooms were decorated and furnished to a very good standard and had been personalised by the service users. 40 FIR TREE ROAD Version 1.10 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staff recruitment policies do not currently ensure that appropriately competent staff are employed by the organisation. EVIDENCE: There are appropriate training opportunities in place for staff. There are arrangements in place for all staff to have regular access to training and a commitment from the organisation to provide staff with NVQ training. Four members of staff have NVQ Level 2. There are currently sufficient staff employed to meet the needs of the service user group, who are all of high dependency. Staff are able to work on a one to one basis with Service Users. Community Integrated Care currently manages recruitment. Two written references are required for all staff and Criminal Records Bureau checks will be carried out on all future staff. The manager is involved in all aspects of staff recruitment and equally importantly staff induction programmes. However it is of concern that recently recruited staff do not have sufficient understanding of English. Service Users in this service are unable to communicate verbally and therefore it is of crucial importance that newly recruited staff can be fully understood by Service Users. Please see requirements. 40 FIR TREE ROAD Version 1.10 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 There is good leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. The manager is fully aware of the needs of the Service Users in the home and as such is able to communicate this to staff through regular staff meetings and individual supervision sessions. EVIDENCE: The manager is qualified to NVQ Level 3 and is currently studying for NVQ Level 4 and the Certificate in Management. She was appointed as manager of the service on 16/7/04 and has recently been registered with CSCI. The following records were examined during this Inspection: Service Users Care Plans, Service Users Medication Records, the Staff Rota and Menus. 40 FIR TREE ROAD Version 1.10 Page 16 These records were in good order. Staff were noted to receive training in matters of health and safety and ample information was available to advise staff as to safe practice, including lifting and the handling of corrosive materials. There is a Health and Safety procedure in place. 40 FIR TREE ROAD Version 1.10 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 40 FIR TREE ROAD Version 1.10 Page 18 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 OP29 Regulation 18(1)(a) Requirement It is required that all newly recruited staff are able to fully verbally communicate with Service Users and colleagues Timescale for action With immediate effect as from 5/04/05 2. 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. Refer to Standard Good Practice Recommendations There are to be no recommendations from this inspection 40 FIR TREE ROAD Version 1.10 Page 19 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 40 FIR TREE ROAD Version 1.10 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!