Inspection on 04/10/05 for 44 Massetts Road

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

44 Massetts Road 12/03/09

44 Massetts Road 13/02/07

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 Kenneth Dunn Announced Inspection 4th October 2005 10:00 Massetts Road (44) DS0000013503.V253608.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 Massetts Road (44) DS0000013503.V253608.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. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 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.V253608.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 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 situated directly off of the kitchen. The service is close to all the local facilities and amenities of the town 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 Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the home’s second inspection for the year 2005/2006. This was an announced visit, which meant that staff and residents were aware that it was due to happen. The CSCI received written feedback forms from 4 service users and this has been incorporated into the body of this report. The home had a comprehensive statement of purpose, which accurately depicted the services provided by the home. The service plans in place were comprehensive and are reviewed on a regular basis to ensure that they accurately depict service users’ needs. The home provided a high level of individualised support to service users. This was a commendable part of the home’s operation. Links with service users friends and family were well developed and maintained by the operation of the home. Service users’ health needs were well met. The home has a robust complaints procedure. There have been no complaints received either by the service or by the CSCI in relation to this service. The home is well maintained and furnished to good standard. 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. Massetts Road (44) DS0000013503.V253608.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 Massetts Road (44) DS0000013503.V253608.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): 5 The service users benefit from clear and user-friendly contracts that fully outline the organisations position and the service users own obligations. EVIDENCE: All service users have an Assured Tenancy Agreement. The inspector reviewed the services copies held on the individual service uses files. The agreements were fully signed and dated by the service users and a representative of the service. In discussions with service users during the inspection they all understood that they had a contract (agreement) with the home and retained a copy of it in their bedrooms. One service users explained that it had been fully discussed with him and although he could not remember all of it he did understand his rights. Massetts Road (44) DS0000013503.V253608.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): 8 There is very good open consultation within the home and the organisation encourages feedback from all of the service users. EVIDENCE: The service is dedicated to ensuring that the service users have a voice within the home and the organisation. There are several forums for service user involvement within the home. One of the main sources of participation is the regular service user meetings where the residents can raise issues and worries to the staff team. The manager stated that it is then his responsibility to disseminate this information either within the home or throughout the organisation. The organisation has produced policies and procedures to ensure that all service users have a voice and can fully participate in the running of their home. The comments cards returned to the inspector from the service users unanimously indicated that while they may have the opportunities to be involved in the home they do not wish to be more involved in the decision making within the home” Massetts Road (44) DS0000013503.V253608.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): 12, 13 The Manager and staff enable the service users to maintain appropriate and fulfilling lifestyles in and outside the home. EVIDENCE: All Service Users have full and varied activity programmes. Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They are encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. There is good evidence within the service users files to indicate that the activities programmes were individualised in accordance with service users wishes and made appropriate use of community amenities and facilities. The comments received during the inspection fully supported the written information in the files and the service users agreed that the staff did support them and they were encouraged to pursue individual interests and hobbies. There was evidence in the care plans that service users are supported to be as independent as possible, and are free to make decisions where possible. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 10 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): 21 The manager and the staff group have a good understanding of the service users support needs. This was evident from the positive interactions and relationships observed. However the policies and procedures within the service do not support the local knowledge. EVIDENCE: The inspector reviewed the current policies and procedures designed to deal specifically with ageing, illness and death and these were found to be still incomplete. The Inspector has previously made requirements on the services to ensure that their procedures were inline with standard 21 of the National Minimum Standards most recently on the 9th of December 2004. The manager must ensure that the service has a set of procedures fully reflective of the National Minimum Standards. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 11 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 There is a clear and effective complaints and compliments procedure in place. Complaints information is available to service users. EVIDENCE: Policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. Regular residents meetings are held so that views are listened to and acted upon A log is now kept available for all minor complaints, issues and niggles. The log was reviewed and it contained only one minor issue which had been resolved by the manager the same day as it was documented. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 Evidence gathered during this inspection confirmed that the home meets each of the assessed standards and provides a good level of accommodation appropriate to the needs of the current service users. EVIDENCE: The home is spacious, comfortable clean and free from odours. The furnishing, fitting and equipment are of satisfactory quality. None of the service users have any physical disability therefore no adaptations have been necessary. The resident’s bedrooms were personalised and reflect the individual’s choices and tastes in addition there were some photographs of family members and friends. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 13 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 Staff in the home have a good understanding of the needs of the Service Users and are appropriately supported by the manager on a regular formal and informal basis. EVIDENCE: On the day of the Inspection a member of staff was observed to be undertaking a number of roles including working with a Service User who needed some assistance with everyday tasks. 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. The Home is committed to a rolling programme of NVQ training for all staff. Staffing levels at the time of the inspection comply with National Minimum Standards. It is essential that the manager base his staffing needs on the funding agencies needs assessment on the service users. Staffing levels must remain at the level previously agreed by the homes regulatory body. All possible alterations in the future can only be based upon a full review of the service users needs and the dependency level set by the funding agencies. The manager is involved in all aspects of staff recruitment and policies and procedures were in place for recruitment and employment. Records of good practice were seen in the Home. The recruitment procedure was observed to be robust. There are arrangements to carry out CRB checks and two written references are required for all staff. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 14 Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41, 42 & 43 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: Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 16 The frequency of staff meetings, formal and informal supervision is indicative of an open and supportive atmosphere nurtured by the manager. Regulations 26 (Monthly visits by the proprietor) are undertaken and evidence was seen of their occurrence. Relevant policies and procedures were in place. Systems existed to demonstrate these had been communicated to staff. Also those of relevance to service users had been shared with them. Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. They were seen to be in good order. There were policies and procedures in place for the health, safety and welfare of service users and staff. 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. The service has a detailed Health and Safety procedures in place in relation to safe working practices. Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 17 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 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Massetts Road (44) Score X X X 1 Standard No 37 38 39 40 41 42 43 Score X X X X 3 3 3 DS0000013503.V253608.R01.S.doc Version 5.0 Page 18 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 YA21 Regulation 12(1 & 4) 37 18(1)(a) Requirement The manager must ensure that the service has a policy covering the ageing process within the service user group. The manager must ensure that staffing figures are fully based upon the dependency level set by the funding agencies. Timescale for action 04/10/05 2 YA33 15/11/05 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 Standard Good Practice Recommendations Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 Page 19 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 Massetts Road (44) DS0000013503.V253608.R01.S.doc Version 5.0 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. 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