Inspection on 13/10/05 for 56 Chart Lane

This inspection was carried out on 13th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

56 Chart Lane 15/05/07

56 Chart Lane 02/06/05

56 Chart Lane 17/09/04

56 Chart Lane 09/06/04

56 Chart Lane 12/02/04

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Chart Lane (56) 56 Chart Lane Reigate Surrey RH2 7DZ Lead Inspector John Chivers Unannounced Inspection 13th October 2005 11:00 Chart Lane (56) DS0000013520.V255382.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 Chart Lane (56) DS0000013520.V255382.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. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chart Lane (56) Address 56 Chart Lane Reigate Surrey RH2 7DZ 01737 224592 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) Royal Mencap (Housing & Support Services) Ms Alison Jane Porteus Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 25 65 YEARS 2nd June 2005 Date of last inspection Brief Description of the Service: The service is administered by Royal Mencap (Housing and Support Services.), and is one of many services managed by the organisation. The home is registered to accommodate a maximum of eight residents all of whom have a learning disability. The age range of the residents is 25 - 65 years. The home is located in a residential road with a range of facilities and amenities close by. The home provides a safe, comfortable and accepting environment, where resident’s can develop their potential and experience a homely and caring service and are well supported by staff. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 13th October 05. The duration of the inspection was 1.75 hours. All of the CSCI ‘Core’ Standards were assessed at the previous inspection; therefore a number of ‘None Core’ Standards were inspected on this occasion with the exception of Standards 22 and 23, which were again re-visited. As part of the inspection process discussion was held with three residents, one member of staff and the home’s management. Samples of policies, procedures and records were examined. The findings of the inspection were again positive with continued evidence of sound management and care practice. Staff were observed to be committed, competent and enthusiastic. Relationships between staff and resident’s were observed to be positive, friendly and relaxed. Resident’s contracts/terms and conditions of residence were in place and documentation regarding residents personal support plans were held. The home provides a wide range of stimulating and purposeful activities. Appropriate policies and procedures were in place and the samples of records inspected were well kept. Staff supervision is held on a regular basis and the home is committed to NVQ training for its staff. There are no requirements or recommendations as a result of this inspection. What the service does well: The service continues to be managed in a sound and professional manner and provides a very good standard of ‘all round’ care to the residents. Of particular noteworthiness was the range of activities that residents are encouraged to take part in and the empowerment of residents to make decisions and participate in the daily life of the home. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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 Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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): 4 and 5. The home has a clear admissions procedure and protocol and ensures that residents have written contracts/terms and conditions of residency. EVIDENCE: The arrangements for admission into the home are detailed in the home’s procedure manual and referral protocol. Admissions are usually stage and include day and weekend visits followed by a six-week trail period prior to permanent residency. Samples of referral forms were available. Contracts/terms and conditions of residency were available in the sample of resident’s files inspected. The contracts had been signed by the individual residents. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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 the following standard(s): 7 and 8. The home has regard for encouraging resident’s to make decisions and participate in the day to day running of the home. EVIDENCE: Evidence of resident’s involvement in decision-making is detailed in individual resident’s ‘person centred plans’. Further evidence was available via activity charts and minutes of residents meetings. Residents participate in the general running of the home and a list of ‘house rules’’, which had been developed and agreed by the residents, was displayed. The house rules were sensible, realistic, fair and attainable. Resident’s stated in discussion that they “have a say” in the running of the home. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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 the following standard(s): 14 and 17. The home has a positive regard for encouraging and enabling residents in purposeful activities. The home ensures that residents have a balanced diet, have a choice of meals and are provided with the opportunity to assist in meal preparation. EVIDENCE: The home continues to provide a wide range of stimulating and purposeful activities for the residents. The activities include sedentary and active pastimes. Some resident’s have their own art exhibitions displayed at local centres. This, in the inspectors view is a commendable achievement. The home has recently acquired a ‘house car’, which now affords resident’s more outings. Four of the home’s staff are authorised to drive the care. During the inspection some of the resident’s returned from a shopping expedition accompanied by a member of staff. Resident’s stated that they enjoy such shopping trips and assisted staff in storing provisions in cupboards and refrigerators etc. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 Page 11 The home’s menu provides for a balanced diet. This was also evidenced by the range and quality of provisions purchased on the day. Copies of menus were held and dated back to 20004. The home’s kitchen is a domestic size and is well equipped. Provisions are safely and correctly stored and refrigerators and freezers were kept at the required temperatures. The temperatures are taken and recorded on a daily basis. Resident’s regularly assist in the preparation of meals subject to written individual risk assessments. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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 the following standard(s): 18. The home is competent at providing residents with personal support consistent with their assessed needs. EVIDENCE: Personal support needs are recorded in resident’s ‘person centred’ plans. There was evidence of such needs being reviewed and updated in the sample of resident’s files inspected. Written risk assessments are also included are also included within the plans. Resident’s stated in discussion that their needs are met and that staff look after them well. There was evidence of appointments with the home’s GP and other health care professionals regarding specialist support and input. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23. The home takes any complaint seriously and ensures such matters are thoroughly investigated. The home takes positive steps regarding resident’s safety and protection. EVIDENCE: The home has a written complaint procedure. In addition there is a complaint procedure in pictorial form for the residents. The home’s complaint file was available. There were a small number of ‘minor’ complaints from residents complaining mainly about other residents. Nevertheless there was evidence that the complaints were taken seriously, investigated consistent with the home’s procedures and included and outcome. Resident’s stated in discussion that they had no complaints of concerns about the service they receive. Residents were clear that the staff treat them well and look after them properly. The home had an internal Adult Protection procedure. In addition the home held the Surrey County Council Multi-Agency Adult Protection procedures. All staff have received training in the protection of Vulnerable Adults. Samples of the resident’s personal finances were inspected. The cash held was consistent with the balance in the cashbook. Residents stated in discussion that they felt “safe and protected” in the home. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 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 the following standard(s): 29. The premises are consistent with requirements and do not require any special adaptations or equipment. EVIDENCE: A full inspection of the premises was undertaken at the last inspection and no requirements or recommendations were made. The home does not currently require any special adaptations or equipment. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 Page 15 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): 32 and 36. The home has a competent, experienced and skilful staff team, which enables the home to meet its aims and objectives. The home is committed to ‘formal’ staff supervision. EVIDENCE: The home is adequately and competently staffed. The staff have a range of skills and experience, which enables the home to meet its aims and objectives. Staff were observed to work with the residents in a caring, committed and enthusiastic manner. Relationships between them were positive and relaxed and the atmosphere in the home was welcoming and friendly with an abundance smiles, positive facial expressions and laughter from the residents. The home has a comprehensive written induction programme for new staff. Currently two staff are undertaking the NVQ level 2 award and funding has just been agreed for another member of staff to commence the course. The manager is currently studying for the Registered Managers Award. There was evidence of ‘formal’ individual staff supervision and written notes of such sessions were available. The manager stated that the organisation does not yet have a formal system of annual staff appraisals; however this is due to be introduced in the near future and the manager has recently attended a ‘staff appraisal’ course in preparation for its implementation. As this is in progress a requirement will not be made. Chart Lane (56) DS0000013520.V255382.R01.S.doc Version 5.0 Page 16 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): 37. The home is managed in a sound and professional manner and affords a very good standard of care to the residents. EVIDENCE: The home’s manager has substantial experience at both practice and management level regarding services for people with learning disabilities and this is evidenced by the findings at this inspection. The manager is currently undertaking the Registered Managers Award. The home’s Certificate of Registration was prominently displayed. Chart Lane (56) DS0000013520.V255382.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 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 4 4 X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X N/A X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 4 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chart Lane (56) Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000013520.V255382.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Chart Lane (56) DS0000013520.V255382.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. 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