Inspection on 22/12/05 for 5-7, Cedars Road

This inspection was carried out on 22nd December 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 found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5-7, Cedars Road 06/09/07

5-7, Cedars Road 06/07/06

5-7, Cedars Road 12/07/05

5-7, Cedars Road 16/12/04

5-7, Cedars Road 24/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Cedars Road, 5-7 5-7 Cedars Road Hampton Wick Kingston-upon-thames Surrey KT1 4BG Lead Inspector Simon Smith Unannounced Inspection 22nd December 2005 11:30 Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cedars Road, 5-7 Address 5-7 Cedars Road Hampton Wick Kingston-upon-thames Surrey KT1 4BG 020 8943 2668 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) Richmond Homes for Life Trust Ms Jackie Harris Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: The property is owned and maintained by the Richmond Churches Housing Trust. The service is operated and managed by Richmond Homes For Life Trust. The Homes For Life Trust is a registered charity operating a number of services locally, including supported living projects and a leisure break scheme. The home is situated in a quiet residential street, although benefits from proximity to public transport networks and good shopping and community facilities. A high standard of decoration has been achieved throughout the home and the property has a large, well-maintained garden. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the course of a single visit and involved speaking to residents, the manager and members of staff. A sample of records was examined and a tour of the building made. The inspector was made welcome and wishes to thanks residents and staff for their help during the inspection. The home met 21 of 27 National Minimum Standards assessed at this visit. 6 Standards were almost met and 8 Requirements were made. The home had generally responded well to the last inspection report, showing particular improvement in the area of NVQ training for staff. One Requirement from the last report had not been met as the Trust has yet to produce a written Service User Guide. What the service does well: What has improved since the last inspection? Licence agreements have been produced in a format that is more accessible to residents. All but one of the staff team have achieved or registered for National Vocational Qualifications. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 6 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. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Written information about the services provided by the home must be improved. Residents’ needs and strengths are effectively assessed. Licence agreements issued to residents must contain all information specified in the National Minimum Standards. EVIDENCE: The Homes for Life Trust has yet to produce a Service User Guide, an issue which has been highlighted for action in the last two inspection reports. The manager advised that the Trust has commissioned the production of a video for the Service User Guide and that the person appointed to make the film has visited the home to meet residents and seek their views. Whilst it is commendable that information about the home will be available in video format, the Care Homes Regulations (2001) require that the Service User Guide is also available in writing. The Trust must ensure that all information required by the Care Homes Regulations (2001) is included in the written Service User Guide. See Requirement 1. Care plans indicated that residents’ needs are effectively identified through the assessment process and that this information forms the basis of care and Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 9 support delivered. The home is committed to ensuring that individual plans are person-centred and reflect the needs and aspirations of residents. The home is registered to accommodate residents between the ages of 18 and 65 years. The manager advised that one resident has reached the age of 65. The Registered Person must therefore submit an application to the CSCI to vary the home’s registration category. See Requirement 2. New licence agreements have been issued to residents by the Trust in recent months. The manager advised that the terms and conditions outlined in the new agreement are almost identical to those in the old document but that the new agreements are more accessible to residents. It is acknowledged that the new format introduced is clear and more user-friendly. However the Trust must ensure that the new licence agreements contain all information specified in Standard 5 of the National Minimum Standards. See Requirement 3. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 10 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): 7, 8, 10 Residents are consulted about issues that affect them in the home. Residents are involved in the running of the home. Residents receive good support to make informed decisions about their lives. Sensitive information is stored and handled appropriately. EVIDENCE: Staff demonstrated a good knowledge of residents’ individual needs and a commitment to supporting residents in making informed decisions about their lives. Observation confirmed that residents are able to choose the way in which they spend their time at the home. The service consults significant others, such as family members and care managers, where appropriate regarding the care of residents. Residents are consulted about how the home runs and meet as a group on a monthly basis. The last residents meeting on file took place on the 15th December 2005. Residents are supported to access advocacy services if they Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 11 wish to do so. There is an expectation that residents will involve themselves in the routines of the home such as cleaning, shopping and cooking. Residents are also expected to maintain their own bedrooms and manage their own laundry. Staff work within the home’s Confidentiality policy. The policy sets out clear guidelines for staff concerning the storage, access, handling and usage of confidential information and has been developed with appropriate reference to the Data Protection Act (1998). All sensitive information was found to be stored appropriately within the home. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 12 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): 11, 12, 13, 15, 16, 17 Residents are encouraged to involve themselves in the routines of the home and to develop independent living skills. The manager and staff are committed to supporting residents in community participation. Residents receive good support to develop and maintain relationships with their families and friends. The home’s menu is varied, well balanced and is developed with input from residents. EVIDENCE: Residents are encouraged to develop the skills required for independent living through involvement in the routines of the home, such as cooking, cleaning and shopping. Some residents are able to travel independently. Residents are actively involved in their local community, using shops, cafes, pubs and other community resources. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 13 All residents have settled programmes of day opportunities, which include supported employment, college and resource centre attendance. Most residents attend the Avenue Centre for four days each week. The manager advised that the Avenue Centre has allocated a linkworker to the home, who visits weekly to work with residents. One resident informed the inspector that he had finished college for the year and he planned to return in January. The resident also advised he continues to enjoy his job. Most residents have regular contact with their families and the manager reported that all residents planned to stay with their families over the Christmas period. Residents are supported by staff to visit family members if their relatives are unable to visit the home. For example, staff support one resident to visit a relative who recently moved into a care home. One resident recently celebrated a significant birthday with a party attended by approximately eighty friends and family members. The resident said that he had worked with the manager and staff to prepare for the party and had greatly enjoyed the event. Interactions between staff and residents was positive during the inspection. Residents have unrestricted access to all communal areas of the home. Residents’ wishes and needs are clearly identified in their individual plans. Staff used appropriate forms of address when speaking to residents. Residents meet regularly to choose the home’s menu. The advertised menu indicated that the home provides a varied and well-balanced diet. Responsibility for cooking and preparing food is shared amongst residents and the staff team. All staff undertake basic food hygiene training as part of their induction process. Standards of food hygiene and storage at the time of inspection were good. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Residents receive good support to access community and specialist healthcare resources where necessary. Changes in need are effectively identified and receive an appropriate response. The recording of medication administration must improve. Guidance for staff and risk assessment regarding residents’ sself medication must improve. EVIDENCE: All residents are registered with local general practitioners and access other community healthcare resources as necessary. Staff on duty demonstrated a good knowledge of residents’ healthcare needs and an awareness of individual guidelines for delivering care. The inspection provided good evidence that any changes in residents’ needs are effectively identified and that staff respond appropriately to these changes. For example, the manager was able to demonstrate that the home is seeking to identify any changes in residents’ needs due to aging. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 15 There is an appropriate system for the storage and administration of medication. All medication coming into or leaving the home is recorded. There are clear protocols governing the administration of medication. Inspection of medication records for four residents indicated two errors in recording on Medication Administration Record sheets. The manager was aware of the errors and advised that she had addressed this issue with the staff team. See Requirement 4. One resident currently self medicates. This is addressed on the resident’s care plan but the guidance available for staff should be developed to ensure that clear information is provided for all those involved in the resident’s care. The resident should be involved in the development of these guidelines if possible. See Requirement 5. In addition, a risk assessment should be performed to ensure that risk factors associated with self-medication are identified and managed appropriately. See Requirement 6. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Appropriate guidance is provided for staff in the recognition, prevention and reporting of abuse. EVIDENCE: The home works within the framework of the local authority‘s ‘Joint Policy on Suspected Abuse of Vulnerable Adults’. The policy offers definitions of abuse and provides guidance for staff in the recognition and reporting of abuse. The Trust also has a Whistle-blowing procedure, which provides a mechanism for staff to register any concerns they have about malpractice. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 The home is comfortable, safe and well decorated. The communal rooms of the home are welcoming and homely. Residents’ bedrooms reflect individual preferences. The home is clean and hygienic. EVIDENCE: The home is situated in a pleasant residential area and has good access to local community facilities, open spaces and public transport networks. A high standard of decoration has been achieved throughout the home and the property has a large, well-maintained garden. The adjacent garage has been converted to a games room, which provides activities such as snooker and table football. Communal rooms include an open plan kitchen/dining area (which provides direct access to the garden) and a separate lounge. Toilet and bathroom facilities are available on both floors of the home. Communal rooms were Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 18 welcoming and homely and private accommodation indicated individual tastes and preferences. All areas of the home were clean and hygienic. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36 Systems of communication amongst staff are clear and effective. Staff are encouraged to undertake qualifications relevant to their roles. Staff receive effective support and supervision, although this must be extended to include regular bank staff. EVIDENCE: A clear shift plan was in place, which listed residents’ appointments and activities and identified the member of staff responsible for support. Handovers are given by staff finishing their shift to those beginning work. A communication book and house diary are maintained. One member of staff recently achieved the NVQ level 3 award, whilst two other members of staff are working towards NVQ level 3. Two staff are registered for NVQ level 2. The manager has completed the Registered Managers Award and is working towards NVQ level 4. Staff are individual bank staff the home provided with effective line management support and receive supervision every two months, although supervision sessions for have not taken place this often. Where bank staff are employed at on a regular basis it is important that they receive the levels of DS0000017355.V261276.R01.S.doc Version 5.1 Page 20 Cedars Road, 5-7 guidance and support afforded to members of the permanent staff team. See Requirement 7. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41, 42 The home aims to seek and respond to residents’ views. The Registered Provider must improve the monitoring of the service. The health and safety of residents and staff within the home is maintained. EVIDENCE: The home aims to seek residents’ views through regular meetings, which are supported by staff. Residents are encouraged to involve themselves in the routines of the home and are consulted about decisions in the home that affect them. (See also Standard 8). The Care Homes Regulations (2001) require the Registered Provider to make monthly monitoring visits to the home and to submit reports of these visits to the CSCI. Reports of monitoring visits have not been received by the Commission thus far and must be submitted by the Trust in future. See Requirement 8. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 22 The home has an appropriate fire detection system, which is tested regularly by staff. The home’s fire fighting equipment was checked in May 2005. Clear instructions for use in the event of a fire were prominently displayed. The home was clean, hygienic and free of obvious health and safety hazards on the day of inspection. Standards of food storage were satisfactory. All substances potentially harmful to health (COSHH products) were stored appropriately. The home maintains an Accident book. There is a clear procedure to be followed should a resident go missing. Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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 2 2 3 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 X 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X X X 3 X 2 3 X Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last Yes 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 YA1 Regulation 5 Timescale for action The Registered Person must 30/01/06 produce a Service User Guide and supply a copy to each resident and to the CSCI. (This Requirement is reinstated from the last inspection). The Registered Person must submit an application to vary the home’s registration category. The Registered Person must ensure that the licence agreements issued to residents contain all information specified in Standard 5 of the National Minimum Standards. The Registered Person must ensure that all medication administered is accurately recorded. The Registered Person must ensure that appropriate guidance is provided to staff regarding residents’ self medication. The Registered Person must ensure that risk assessments are performed for all residents who self medicate. The Registered Person must ensure that bank staff employed DS0000017355.V261276.R01.S.doc Requirement 2 3 YA3 YA5 24 5(1)(c) 30/01/06 30/01/06 4 YA20 13(2) 30/01/06 5 YA20 13(2) 30/01/06 6 YA20 13(2) 30/01/06 7 YA36 12(5) 30/01/06 Cedars Road, 5-7 Version 5.1 Page 25 8 YA41 26 at the home on a regular basis receive appropriate levels of supervision. The Registered Person must make monthly monitoring visits to the home and submit reports of these visits to the CSCI. 28/02/06 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 Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Cedars Road, 5-7 DS0000017355.V261276.R01.S.doc Version 5.1 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. 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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