Inspection on 13/02/07 for 44 Massetts Road

This inspection was carried out on 13th February 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

44 Massetts Road 12/03/09

44 Massetts Road 04/10/05

44 Massetts Road 05/05/05

44 Massetts Road 09/12/04

44 Massetts Road 08/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Massetts Road (44) 44 Massetts Road Horley Surrey RH6 7DS Lead Inspector Helen Dickens Unannounced Inspection 13th February 2007 10:45 Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 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 Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 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. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Massetts Road (44) Address 44 Massetts Road Horley Surrey RH6 7DS 01293 822161 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) Prospect Housing and Support Services Mr Stephen Tidey Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: 44 Massetts Road is a large detached house situated in a residential area of Horley, Surrey. Accommodation is arranged in single bedrooms over two floors. The communal areas, all situated on the ground floor, consist of a large lounge and conservatory and a dining room which is directly off the kitchen. The service is close to all the local facilities and amenities and benefits from good transport links throughout the area. There is a large well cared for garden to the rear of the house and adequate parking spaces at the front. The cost per person per week is currently £924.07. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over 6.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Acting Manager represented the establishment. A partial tour of the premises took place. Discussions were held with three residents and two staff members. A visiting professional, and three other residents, were spoken to during the inspection. Two resident’s care plans and a number of other documents and files, including two staff files, were examined during the day. CSCI would like to thank the residents, staff and Acting Manager for their hospitality, assistance and co-operation during the inspection. What the service does well: The service offers a very pleasant, comfortable and homely environment, which is appreciated by residents who made some very positive comments about the home and its staff. The environment is bright and cheerful, and the atmosphere is relaxed and friendly. Residents were well cared for and their needs had been properly identified and documented. They were encouraged to be independent and to play an active part in the home assisting with cooking, shopping, and with their own cleaning and laundry. Skippy the cat also resides at 44 Massetts Road and he is well thought of by residents who help to feed and look after him. Residents are offered a healthy diet of mainly home cooked food and those spoken to said they were pleased with the arrangements for food and mealtimes. Quality assurance processes are very good at this home and the service regularly monitors how well they are doing, taking into account the views of residents and other stakeholders. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 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 Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective resident’s individual needs and aspirations are assessed prior to admission to this home. EVIDENCE: Two resident’s files were sampled and found to contain a good level of preadmission information. The home has a ‘pen portrait’ which is a summary of each resident’s background and needs on each file. Assessments from previous placements and specialist assessments from members of the wider multidisciplinary team (including care managers, mental health social workers and health consultants) were available. It was also noted that resident’s had signed these assessments, indicating they had been involved in the process. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are reflected in their care plans and they are supported to make decisions and take risks as part of an independent lifestyle. EVIDENCE: Two care plans were sampled and found to contain a good overview of resident’s needs. The Care Programme Approach is used at this home as all residents have mental health needs. Resident’s needs in relation to their environment, communication, personal and health care etc were documented. Resident’s ‘Strengths and Needs’ formed the basis for the plan and specific goals were identified and followed through with residents. Progress on these goals was noted. Resident’s had signed these plans, indicating their involvement and agreement to the process. Those care plans sampled had been reviewed recently. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 10 Resident’s were encouraged to make decisions in their day-to-day lives and several examples were noted during the inspection in relation to activities both inside and outside the home. Where there were limitations, policies were in place and a record kept. For example, residents are able to smoke in the home. However, they are encouraged to do this in the conservatory, a very pleasant room with comfortable furniture and a TV, which overlooks the garden. Alcohol is not allowed within the home except on special occasions and only when supervised by staff. Illegal substances (drugs) are never allowed. Residents are clear about these limitations and the acting manager stated they were all involved in drawing up the ‘house rules’ which sets out the policies on the above subjects in more detail. Residents were observed to come and go as they pleased throughout the day, alerting staff when they were about to leave and on their return. Residents are supported to take responsible risks and a number of risk assessments were noted on their files. Risk management strategies were in place regarding activities of daily living, holidays and outings, privacy, selfmedication and change in environment. The risk assessments sampled were very personalised and related specifically to each resident. For example, were a resident was at greater risk from a change in the environment, or from financial abuse, tailor made risk assessments were in place. Actions are taken to minimize hazards. For example the roots of a tree are beginning to lift the flagstones on the patio so it has been cordoned off with hazard tape and quotes are being taken to get this work done. The acting manager has considered the risks and taken appropriate action but a documented risk assessment must also be in place. A further written risk assessment is also needed in relation to the radiators and a Requirement will be made in this regard. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in appropriate activities. They are encouraged to be part of the local community and to make and maintain appropriate personal relationships. Resident’s rights and responsibilities are recognised in their daily lives. Residents are offered a healthy diet of mainly home cooked food, and enjoy their meals and mealtimes at Massetts Road. EVIDENCE: Residents are assisted to find appropriate jobs, continue their education and take part in fulfilling activities. There is a weekly rota listing resident’s work placements. Several residents were working at Assembly Matters and the acting manager stated that one resident had just been given an excellent report on his performance there. Another resident works at Prospect Housing Head Office – he carries out administrative tasks and assists in the compilation of the monthly newsletter. Though the home promotes equal opportunities for residents (this is discussed elsewhere in the report), the acting manager stated Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 12 that there is still a stigma attached to mental illness and this makes it more difficult for residents to find and keep meaningful employment and occupation. Residents are encouraged to have meaningful activities within the home including a being on the rota for assisting with cooking. Residents also keep their own rooms clean and tidy, do their own laundry and help with the shopping and looking after the home’s cat. There are a variety of therapeutic daytime activities available to residents including lunch clubs and a young persons group if they wish to attend. The acting manager stated that the home gets on well with its neighbours and a nearby home has started a ‘Friday Club’ and has invited the residents from Massetts Road to join them. One resident is involved in adult education and the acting manager stated that another is hoping to pick up on their GCSEs via the Richmond Fellowship. Resident’s spoken to raised no negative issues in relation to their activities. Residents use the local community facilities including public transport (one resident told the inspector he used his bus pass quite a bit) and local doctors, dentists and opticians. The acting manager stated there has been no problem for residents accessing local health services. Residents also use local pubs and restaurants, and go to the cinemas in neighbouring towns. Those residents interviewed were knowledgeable about local facilities and specifically mentioned using the post office, the model shop, and a local well-known department store. Staff spoken to were knowledgeable on resident’s family links and supported residents to keep in touch. Some residents visited their families regularly and family and friends were encouraged to visit the home. The visitor’s policy sets out visiting times, though it stated these were flexible. Residents can have friends to stay overnight, by arrangement with the home. Resident’s care plans sampled identified any support needs regarding personal relationships. The registered manager of this home was awarded employee of the year by Prospect Housing after being nominated by the relatives of one of the residents. Residents were observed to be treated respectfully by staff. There were many instances during the inspection were staff knocked on doors but did not enter until the resident came to the door and invited them in. Residents have locks for their doors. One resident, when asked if staff went into his room without permission, said they would only do this if they were looking for him and he reported no concerns on this matter. One resident had made a complaint about staff entering their room and this was satisfactorily dealt with by Prospect Housing Head Office. There were no instances of staff talking exclusively with each other but several examples where staff stopped or changed their conversation in order to include a resident who had joined them. Residents decided for themselves when they Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 13 wanted to be alone or in company – the layout of the home allowed for both options with everyone having a private bedroom, and access to the large lounge, dining room, conservatory, and the garden. The home feels spacious and bright and was very comfortably furnished. The home’s pet, Skippy the cat, looks very well cared for by residents who, according to the acting manager, all help with feeding and looking after him. Rules on smoking, alcohol and drugs are clearly set down, following consultation with residents who helped to draw up the ‘house rules’. Residents are offered a healthy and balanced diet of mainly home cooked food and those residents spoken to stated they enjoyed their food and mealtimes; one described it as ‘Very nice, healthy food’. Four weeks menus were sampled and demonstrated a varied and balanced diet being offered to residents. The dining room was bright and cheerful. Fridges were packed with fruit, vegetables and fresh meat. The evening before the inspection residents had been given home made rissoles made with organic mince. On the evening of the inspection the staff on duty prepared two fresh quiches. One of these was a vegetarian option with peppers and onions, and the other was a traditional quiche lorraine with bacon. The smell of quiches from the kitchen and the residents gathering around in advance of the meal in the adjoining dining room gave the place a very homely feel and demonstrated what a friendly and relaxed atmosphere prevails is in this home. Some residents need a special diet which staff were knowledgeable about, and the dietician has been involved with one resident on an ongoing basis. Residents can help themselves to drinks and snacks and they help with shopping, cooking and setting and clearing the tables. The acting manager stated that residents have input into the menu and staff try to accommodate everyone’s favourite meals. Staff eat with residents in this service, which again adds to the homely atmosphere at Massetts Road. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered personal and healthcare support in the way they prefer and require, and the administration of medication is well organised. EVIDENCE: Residents at this home require little help with personal care but those spoken to confirmed staff would help if this were needed. Staff said guidance and support was sometimes needed. Times for getting up and going to bed are flexible and this was demonstrated at the start of the inspection as some residents had by then already got up and gone out, whilst others were still in bed. Residents were dressed very individually and had clearly chosen their own clothes and hairstyles. Resident’s health needs are well met at this home. One professional interviewed confirmed that the main outcome with regard to placing a resident in this home had been met. Health needs included local GP assessments and check ups, as well as specialist input from the mental health team. These arrangements were documented on resident’s files. Some residents use the Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 15 local specialist NHS therapeutic services, and again this was clearly documented. The acting manager said that the local surgery had re-instated annual health checks for patients, and the residents at this home would benefit by this service. Medication is well organised at this home and one staff member takes responsibility for the overall co-ordination of the arrangements and the ordering of medication. Staff are trained by Propsect Housing and work to the corporate medication policy using in-house medication administration records. These are well set out and were properly completed – only one resident’s record had an unexplained gap and the acting manager looked into this immediately. A list of sample signatures of those staff trained to give medication is on the front of the medication file and only those staff who know residents well administer medication. Resident’s photographs were also on their records. On the day of the inspection, medication was being kept securely. Medicines are supplied by the local pharmacy and by the NHS and there are no controlled drugs at this home. Those residents who had been assessed as able to self medicate had a risk assessment in place. The home is due to have a visit from the community pharmacist and it was recommended that the risk assessments and the method of residents keeping their own medication are reviewed at that time to get the latest best practice advice from the pharmacist. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents concerns are taken seriously and they are protected from abuse. EVIDENCE: The home has a complaints policy called the ‘Grumbles, Gripes and Complaints Policy’ and there was evidence that residents knew about and had used the policy. There was a complaints book and the acting manager monitored complaints as part of the usual quality assurance processes at the home. Two complaints had been received from residents in the last year and both had been dealt with satisfactorily by the home. The home also has a protection of vulnerable adults policy, and has a copy of the Surrey multi-agency procedures for the protection of vulnerable adults, as well as the manager’s toolkit on the same subject. No vulnerable adult issues had been identified since the last inspection. The home has been proactive in identifying areas where these residents may be particularly vulnerable and this had been identified in their risk assessments, and avoiding actions had been taken. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 44 Massetts Road provides a very homely environment for residents and is clean and hygienic throughout. EVIDENCE: A partial tour of the premises took place including all the communal areas and three resident’s bedrooms. The main lounge and the conservatory are very well furnished with comfortable armchairs and sofas which are co-ordinated with the carpets and curtains. There have been a number of improvements since the last inspection including decorating in the lounge and the hallway and refurbishing and decorating some residents rooms. The home is bright, cheerful and spacious throughout and every part of the home was fresh smelling and looked clean. The conservatory is designated as the smoking area but can be closed off from the dining room so the smell of smoke was not noticeable in the rest of the house. The home is close to local amenities and transport and there is a maintenance and renewal programme for the home. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 18 One resident interviewed by the inspector summed up the service by saying ‘….it is homely, and it is comfortable.’ Written risk assessments are needed for the absence of radiator covers and the uneven patio, and this is dealt with above under Standard 9. In addition, some minor decorative matters needed attention including paper starting to peel in the newly decorated lounge and in one area in the hall, and the downstairs bathroom and toilet which needs attention and is due for redecoration – the acting manager said all these issues had already been identified and the decorator was coming in within the next month. The premises are clean and hygienic with good hand washing facilities consisting of liquid soap and paper towels in all communal hand washing areas. In the laundry there is a commercial washing machine and a tumble dryer and hotter programmes (up to 95C) are available if necessary. The floor was impermeable and easy to keep clean. Residents said they did their own laundry and the acting manager said most residents did this independently but support and supervision is available if necessary. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. Recruitment practises are good though further work needs to be done to meet this Standard in full. Resident’s needs are met by appropriately trained staff. EVIDENCE: Staff were observed to be approachable and communicated well with residents who were seen to turn to staff for support and advice. Both the acting manager and deputy were knowledgeable on mental health conditions and on the rehabilitation processes for residents. Staff encouraged residents to be independent. More than 50 of care staff (including regular bank staff) have at least an NVQ2 qualification, and three staff are trained nurses. Prospect Housing have a recruitment policy in place, including an equal opportunities policy in relation to prospective staff. The appropriate checks are taken up including Criminal Records Bureau checks, and establishing a full employment history for new staff. Residents now have the opportunity to be involved in recruitment and can meet with candidates who come for interview Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 20 – the acting manager described how this happened during the latest round of recruitment activity. On the day of the inspection two recruitment files were sampled. A proforma from the personnel department at Prospect Housing contains confirmation that the appropriate checks have been taken up and this is signed off by the Chief Executive. One file sampled had the proforma missing and though this was emailed to CSCI within 48 hours, the Regulations state that this information must be available for inspection within the home and a Requirement will be made in this regard. There is a staff training and development plan in place and the acting manager was able to demonstrate that staff had had mandatory training including annual courses in adult protection, moving and handling, fire safety and health and safety. All staff receive equality and diversity training. Staff receive medication training every two years, and food hygiene and first aid training every three years. All new staff receive induction training and an induction checklist was seen and found to be satisfactory. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and quality assurance processes are very good. The health, safety and welfare of residents are promoted and protected. EVIDENCE: The registered manager was away on secondment at the time of this inspection. He has been the registered manger at this home since 2003 and is a qualified mental health nurse and has the Registered Manager’s Award. During his absence the deputy has been acting manager for the home. She is also a qualified mental health nurse and has a number of other qualifications relevant to working in this field including a certificate in cognitive behavioural Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 22 therapy, and a Masters degree in Mental Health Studies; she is also a qualified assessor. In the absence of the registered manager the acting manager has been responsible for ensuring the aims and objectives of the home are met, the budget is managed properly and the home complies with the Care Standards Act Regulations and Requirements. The home was running very well and both staff and residents were observed to have confidence in the acting manager, turning to her for assistance and guidance as required. Quality assurance processes are very well managed at this home. There is an internal audit carried out as part of their quality assessment framework between homes run by Prospect Housing. A manager from another home comes in and assesses the homes performance under a number of quality headings including service user’s needs, health and safety, and fair access, diversity and inclusion. Feedback is also sought from care managers, GPs etc. There is an in-house quality assurance questionnaire for residents and other stakeholders (last done in January 07) asking about décor and cleanliness, food and menus, rights and complaints, and care. Feedback is given to residents at resident’s meetings, and to Prospect Housing. The acting manager said a ‘social interests’ questionnaire, last carried out in 2005 is being revamped and will be done again in 2007. The home also has Regulation 26 visits carried out by the Provider, and staff and resident’s meetings. There is an annual development plan for the home and a short presentation on the progress of the home is being made to the Prospect Housing Board by the deputy manger of the home. Health and safety arrangements are good at Massetts Road. An audit was carried out in January 2007 and the acting manager said no concerns were raised except the uneven patio which has now been roped off and is awaiting repair. An environmental health department self-assessment questionnaire sent to the home did not result in a follow-up inspection, and the home have a copy of the latest food safety advice folder. Monitoring of fridge and freezer temperatures, and food probe temperatures are being regularly recorded in the kitchen. A system is in place for monitoring the safety of water systems and the acting manager stated that a legionella test had been carried out the previous week. The hazardous substances cupboard was found to be secure, and the appropriate CSCI and employer’s liability certificates were displayed. A shortfall regarding risk assessments has already been dealt with under Standard 9. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 3 X Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation Requirement Timescale for action 15/02/07 2. YA24 13(4)(a)(b) The registered person must (c ) ensure that unnecessary risks to health and safety are identified in written risk assessments with particular regard to the absence of radiator covers and the uneven patio in the garden. 13/03/07 23(2)(b) The registered person must ensure the premises are kept in a good state of repair internally and externally. The minor decorative matters identified in the report should be remedied in a timely fashion including peeling wallpaper in the lounge and hallway; refurbishment due for the downstairs toilet and bathroom; and the repair to the garden patio. 17(2) Schedule 4, 6. The registered person must ensure that the required information on all persons employed at the care home is available for inspection. 20/02/07 3. YA34 Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 25 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 YA20 Good Practice Recommendations The registered person should ensure that during the expected pharmacist’s visit, both the risk assessments and the methods of keeping medication for self-medicating residents should be discussed and advice taken. Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Massetts Road (44) DS0000013503.V327611.R01.S.doc Version 5.2 Page 27 - 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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