Inspection on 23/08/05 for 49 Almond Close

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

49 Almond Close 23/02/09

49 Almond Close 25/03/08

49 Almond Close 20/03/07

49 Almond Close 04/08/06

49 Almond Close 07/04/05

49 Almond Close 03/11/04

49 Almond Close 02/08/04

49 Almond Close 03/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 49 Almond Close Bellfields Estate Guildford Surrey GU1 1NW Lead Inspector Mrs L Garrett Unannounced Inspection 23 August 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 49 Almond Close Address Bellfields Estate Guildford Surrey GU1 1NW 01483 575806 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) Royal Mencap (Housing & Support Services) Ms Alison Jelley CRH (PC) 8 Category(ies) of Learning Disability over 65 years of age registration, with number (LD(E)) 1. of places Learning Disability (LD) 7. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 19 - 65 years of age. 2. One named person may be over the age of 65. Date of last inspection 07 April 2005 Brief Description of the Service: 49 Almond Close, Guildford is a detached property developed to provide accomodation for eight adults with learning disabilities. The home is set in a residential close of similar properties. All rooms are for single occupancyy, none with en-suite facilities. the home offers a sitting room equipped with television and music systems, a dining area, kitchen, utility room for laundry and toilet and washing facilities. There is a garden to the rear of the property and some off road parking to the front. The registered providers are the MENCAP organisation and the Local Authority owns the premises. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Lesley Garrett lead inspector for the service and Gastervous, relief care worker for the establishment until the manager returned to the home at 1130. A tour of the premises took place. The inspector saw five residents and spoke with some of them. This was a positive inspection. The service users will be referred to as residents in this report as the manager stated that is the preferred title. The inspector would like to thank the residents, staff and manager at Almond Close for their time, assistance and hospitality during this inspection. What the service does well: This home has a new manager and this is only her second inspection since taking up the position. She is still working hard on the changes necessary to improve the homes reputation. The staff on duty was happy and helpful with a positive attitude. The residents that the inspector spoke with said they liked it there and had good things to say about the staff on duty. They said they were always busy with plenty of things for them to do. The inspector witnessed the staff respecting the residents privacy by knocking on their bedroom dors and telling the inspector that the residents that wee out had locked their doors and therefore without their permission we could not go into their bedrooms. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 standard(s) 5 Not all contracts and terms and conditions are in place. EVIDENCE: The manager stated that since she has taken up the post of registered manager she has worked hard to streamline the paperwork. Some of the paperwork cannot be found but she has not given up looking. Some of the contracts are at head office she suspects. Some relatives have the contracts and she has found a couple and has placed them in their file, which she showed the inspector. This situation needs to be monitored by CSCI to make sure the manager locates all the relevant paperwork that is required. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 standard(s) 6 & 8 Residents have individual plans of care and they are consulted on and participate in all aspects of life in the home. EVIDENCE: The inspector was shown the resident’s individual plans of care. They were written in conjunction with the resident and the staff had to sign at the back to acknowledge they had read it. These were detailed and included personal profiles, care plans and risk assessments. The manager stated these are reviewed every month and signed for. The manager stated that they no longer have rotas for the residents to do jobs but if they volunteer or particularly enjoy a job then that is all right. They are not forced to do any work. The residents have a meeting every Monday and they are informed of this and join in if they wish. Minutes are held of these meetings and decisions are then documented. A recent meeting discussed what the residents would like to happen with the garden Staff are encouraged to join the meetings including relief workers or agency staff when they are used. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 standard(s) 13 & 14 Residents are beginning to be part of the community and they are allowed to access appropriate leisure activities. EVIDENCE: The manager stated that some of the residents are allowed to go out on their own they only have to tell a member of staff when they do. When a member of staff goes out they see if there is a resident who would like to go. They will go to the local fish and chip shop, Chinese take away and the newsagent. One resident went to the garage to get some cat food but had forgotten to take her purse but the garage recognised the resident and allowed them to have the food and the manager went back with them to pay. The manage stated they now use the garage for milk and small items as they were so friendly to the residents. The residents often go to Guildford to pay their rent and visit the bank and that is where the manager was on the day of inspection with two residents. The residents see their G.P. at the surgery unless they are too ill to go. Most of the residents are out during the day and only have evenings and weekends for leisure activities. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 11 An evening out may consist of a meal in a restaurant or drink at the local pub. They recently went to a local football match and the manager said this was very successful. Residents have also gone to the leisure centre for swimming and one resident enjoys horse riding. Two residents belong to the church and sometimes have evening activities and enjoy the Sunday service. Most residents now see their families at the weekends and holidays are taken with them or in small groups. The residents choose their holiday where they would like to go and with whom. The home has recently purchased a people carrier so no longer have to drive the big mini bus and the staff can also drive the new vehicle. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 12 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 standard(s) 20 The medication at this home is well managed promoting good health. EVIDENCE: The manager stated that only one resident self medicates and the staff help to put the medicines into the dosset box every Sunday then the resident asks the staff for the medication. Risk assessments are in place for this procedure. Boots delivers medication monthly and it comes in blister packs. The manager also showed the returns book that they use. The manager stated that they received a very good service from Boots and there is also a local pharmacy that they can use for antibiotics for example. The medicine cupboard did not have excess stock of medicines and the inspector looked at the MARS chart and no gaps were noticed. The manager told the inspector that medication training is given at induction but unfortunately the certificates have not been issued as proof but she is pursuing this and will organise further training if necessary. All relief MENCAP staff has had training and no one will do the medicines unless they have had the training. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 standard(s) 23 The home has policies and procedures in place and staff have received training. EVIDENCE: The home showed the inspector the surrey Multi Agency policy but it was not the 2005 copy therefore a requirement will be made at the end of the report. The manager stated that all staff had the POVA training and was aware of the policy and procedures although the MENCAP policy is not in line with Surrey’s policy and this too will be a requirement. The manager stated that due to some problems in the past, which is well documented, all residents’ pocket money is checked twice a day. It is checked at the start of the morning shift and at the end of the afternoon. The manager keeps a balance sheet for all residents and at the end of the month this sheet is filed in their administration file. The pocket money tins are locked in the cupboard in the manager’s office. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 standard(s) 24 & 30 There has been no change to the décor or furnishings in the last few months and although this does not pose a risk to the residents it does not create a pleasing environment. EVIDENCE: The inspector noticed the overgrown garden at the front of the property and the grass does need to be cut. The uneven path to the front of the property that was noticed at the last inspection is about to be repaired by the council. The garden to the rear is overgrown and not a pleasant environment to relax in. The manager stated that there had been a recent residents meeting to discuss what to do with the garden, as there is a little money to sort out this problem. The downstairs shower room has tiles missing from the wall and these need to be replaced and there are two doors in the home that needs the handles replacing. The residents will decide at their meeting what they would like in the home as they are now beginning to do but some of the old staff photographs should be removed. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 15 The inspector spoke to four residents and they all told her they enjoyed it at the home and liked living there. The inspector did not see any bedrooms, as she was not invited to look by the residents. The home was clean and tidy and a staff member was busy moping the floors and dusting during the inspection. There were no offensive odours. The manager has had to concentrate on organising the medicines, resident’s files and administration since her appointment but now she should concentrate a little on making this home more homely and making sure repairs are carried out when required. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The home has an enthusiastic workforce that works positively with residents to improve their quality of life. EVIDENCE: The manager told the inspector that following a period of instability the staff have now settled and are familiar faces with the residents. However, they are about to move on to other careers or university and are therefore not prepared to do the NVQ qualification. The home will therefore not have NVQ qualified staff by the end of the year and the inspector will make a requirement at the end of the report for the home to inform the commission on how they will achieve NVQ status. The manager has organised the statutory training including basic food hygiene, manual handling, first aid. The manager starts her RMA in September. The residents that the inspector spoke with said they liked the staff and one resident particularly liked the relief worker that was on that morning. The inspector saw good interaction between staff and residents and they were all relaxed in one anothers company. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health and safety of the residents are not fully protected. EVIDENCE: During a tour of the building and a discussion with the manager the inspector noted that thermostatic valves had not been fitted to the taps but the manager stated that they were due to be fitted soon. The upstairs windows do not have restrictors fitted and this will be a requirement at the end of the report. The inspector looked in the freezer and found that some food had not been labelled or dated and this too will be a requirement. Manual handling training had taken place but the manager stated they do not have hoists and there are no issues with mobility with any of the residents. The fire alarms are tested regularly and all residents know where to assemble should the alarm be activated. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 1 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x 3 3 x x x Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 49 Almond Close Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 19 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 23.1 Regulation 13(6) Requirement Timescale for action 6/9/05 2. 24.1 23(2)(d) 3. 32.6 18(c)(i) 4. 42.2 iv 12 (1)(a) The registered persons shall obtain the February 2005 copy of the Surrey Multi Agency procedure and policy and to ensure that the homes own policy on abuse is in line with that document. The registered persons shall 6/9/05 ensure that the maintenance and decoration of the property is carried out when necessary and not to have long delays. The registered persons are to 6/9/05 advise CSCI how they will achieve the NVQ status by the end of 2005. The registered persons shall 30/8/05 ensure that all food stored in the freezer is labelled and dated. 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. 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 20 Refer to Standard Good Practice Recommendations 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 49 Almond Close H09 H58 s13506 49 Almond Close v236965 230805 Stage 4 unn.doc Version 1.40 Page 21 - 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!