Inspection on 02/06/05 for 56 Chart Lane

This inspection was carried out on 2nd June 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 13/10/05

56 Chart Lane 17/09/04

56 Chart Lane 09/06/04

56 Chart Lane 12/02/04

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 56 Chart Lane Reigate Surrey RH2 7DZ Lead Inspector John Chivers Announced 2 June 2005 @ 10:00am 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. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 56 Chart Lane Address Reigate Surrey RH2 7DZ 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) 01737 224592 Royal Mencap Society Ms Alison Jane Porteus CRH - Care Home 8 Category(ies) of LD - Learning Disability (8) registration, with number of places 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 - The age/age range of the persons to be accommodated will be 25 - 65 years. Date of last inspection 17 September 2004 Brief Description of the Service: The home is owned and managed by MENCAP and is one of many services administered by the organisation. The home is registered for 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 amemities close by. The home provides a safe, comfortable and accepting environment where residents can develop their potential and experience a homely and caring service and are well supported by staff. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place on 2nd June 05. The duration of the inspection was 4.00 hours. No staff were formally interviewed on this occasion as most had been interviewed at the previous inspection. Discussion was held with the home’s management, one member of staff and three of the residents. In addition a range of policies, procedures and records were inspected. A tour of the premises and garden area was also included. The home supplied the CSCI with the required written pre-inspection information. The findings of the inspection were positive with sound management and care practices evident. Staff were observed to be enthusiastic, committed and competent. Most of the staff have substantial experience in caring for adults with a learning disability. The home’s residents were observed to be relaxed and settled in their environment and indicated no concerns about the service provided. The home facilitates activities for the residents and enthusiastically maintains them in college and day centre placements. Whilst some residents could communicate verbally, others communicated by facial expressions, head movements and gestures. What the service does well: The service provides a safe, stable, accepting and homely environment were residents feel protected but can learn, explore and take assessed risks consistent with their individual levels of ability. The staff have formed positive relationships with residents and are committed to communicating with them and are pro-active in motivating and engaging them. The home enables residents to engage in purposeful activities and is to be commended for maintaining all of the residents in college or day centre placements. The home’s recruitment and vetting procedures are sound and management and staff have a clear regard for maintaining a homely and safe environment. The home’s statutory and non-statutory records are kept to a good standard and evidence consistency in recording. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 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. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 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 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 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) 2. The home has a clear regard for obtaining assessment needs information and monitors and reviews these areas on a regular basis. EVIDENCE: Written needs assessments were available in the sample of residents files inspected. There was recorded evidence of resident’s needs being reviewed on a regular basis. The resident’s needs are continuously monitored by staff and recorded in the residents daily care notes. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 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 and 9. The home has a positive regard for care planning arrangements and encouraging residents to take risks consistent with their level of ability and assessed risk areas. EVIDENCE: Written care plans were available in the sample of residents files inspected. The care plans covered a range of areas including: communication, emotional/behavioural development, relationships, motivation, health issues, personal issues, mood swings and skills development. In acknowledging that the care plans are comprehensive it is recommended that the term’ mood swings’ be deleted from the care plan format, as this is more appropriate for people with mental health disorders. Any behaviour changes regarding this could be reported under the emotional/behavioural heading of the care plan format. A recommendation will be made regarding this. Residents are encouraged to take daily risks commensurate to their assessed needs and individual risk assessments. Examples of risks include: Use of taxi’s, use of kitchen, use of electrical equipment, access to Post Office and Bank and dealing with personal finances, staying safe, sun protection and weather awareness. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 10 There was evidence of risk assessments being reviewed and revised as appropriate. Residents indicated in discussion that the home is meeting their individual needs. The home was observed to be meeting the residents needs at the time of the inspection. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 and 16. The home has a clear regard for maintaining residents in college and day centre placements and encouraging and enabling contact with family, relatives and friends and the local community. Activities are viewed as an important part of resident’s development; however it is also important that the home explores ways of enabling residents to have an annual holiday if Placing Authority funds are restricted. EVIDENCE: All of the current residents have college or day centre places. The weekly time table/programme for a sample of residents was inspected. The programmes included: horticulture, exploring music, art and craft, cookery, physical activity/fitness, self-awareness and role-play. The home is to be commended for maintaining all of the residents in college and day centre placements. The home provides a range of activities and enables residents to be part of their local community. Activities include attendance at drama clubs, various 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 12 outings and excursions, walks, cinema, discothèque, visits to local public houses and neighbourhood events. The manager stated that the placing authority have cut funding, which may affect residents annual holidays. If this is the case it would be important for the organisation to have regard for Standard 14.4 of the National Minimum Standards for Care Home’s for Younger Adults and ensure that longer term residents have the opportunity of having a seven day holiday away from the home on an annual basis. Previously residents have enjoyed holidays in the United Kingdom and abroad. The manager stated that all of the residents voted ‘in person’ at the recent general election. All residents have a key worker. During discussion residents were able to say/indicate who their key workers were and stated that key workers and all staff were “good”. Relationships between staff and residents were observed to be positive with interaction and engagement evident. The inspector observed the home’s manager skilfully ‘coaxing’ a resident out of a ‘negative feelings’. The resident quickly recovered into a more positive frame of mind and continued with her art activity. Good humour was also evident in rapport between staff and residents. All staff have received training in maketon. The home’s routine was observed to be that of a normal domestic household. Residents undertake small household tasks and chores. A chores roster is displayed in pictorial form. Resident’s stated/indicated in discussion that they were settled and “happy” with life in the home. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 13 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) 19 and 20. The home has a positive regard for good health/medical arrangements concerning the residents and these areas are monitored and reviewed. Medication arrangements are satisfactory and recent staff training in this area was evidenced. EVIDENCE: Resident’s health care is closely monitored and health/medical details are held in care plans and assessments. Visits to the doctor and other health care professionals are recorded. A range of health/medical related correspondence was available in the sample of resident’s files inspected. The home has an internal policy and procedure regarding the administration of medication. Written guidance from the Royal Pharmaceutical Society is also held. Samples of resident’s medication administered records were inspected. Records were clear and evidenced no gaps in recording. Medication is stored in a locked metal cabinet. Currently none of the resident’s are on ‘controlled’ drugs. The local pharmacy inspects the home’s medication arrangements. The last inspection having been undertaken on 22nd March 05. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 14 All of the resident’s have medication profiles; however only two residents are taking prescribed medication currently. Old or discarded medication is returned to the pharmacy for disposal and a record is kept. It was evidenced that all staff received updated medication training on 18th March 05. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 15 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) 22 and 23. The home has a sound regard for the protection of residents and the training of staff in this area. The home takes any complaint seriously. EVIDENCE: The home has a written complaint procedure. This is also available in pictorial form and in addition is displayed on the resident’s notice board. The home has two complaint books, one for minor complaints from residents and a serious complaint book. The book evidenced that no serious complaints had been received. Resident’s stated/indicated in discussion that they had no complaints about the staff or the service provided by the home. The home has the Surrey County Council Multi-Agency Adult Protection procedures. In addition the home has an internal procedure covering the protection of ‘Vulnerable’ Adults. It was evidenced that staff had received updated training in the protection of Vulnerable Adults between January and February 05. Samples of resident’s personal finances were inspected. Money held was consistent with the balance in the resident’s individual account books. Resident’s indicated that they felt safe and protected in the home. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 16 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, 25, 26,27,28 and 30. The home is maintained in very good order, is attractive, safe, homely and comfortable; however it would be important that the garden is maintained to the same standard. EVIDENCE: The home is a detached property situated in a residential road. Local facilities and amenities are close by. The exterior of the property is maintained in good order. The home has a large rear garden. Currently the garden is maintained by staff and some of their spouses, however the manager stated they sometimes have difficulty in keeping up with garden work in addition to their professional care roles. Whilst it is acknowledged that staff instruct some residents in gardening activities, a requirement will be made that the organisation recruit labour specifically for the heavier and more time consuming tasks. Communal areas are decorated and furnished to a very good standard, are homely and comfortable. A range of pictures and artwork completed by the resident’s is displayed around the home. The artwork is attractive and interesting. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 17 Resident’s bedrooms are of an equal standard and have been tastefully personalised by their occupants. Toilet and bathing facilities are of a good standard and afford adequate privacy. The home has an infection control policy and standards of cleanliness and hygiene were high throughout the home. Resident’s stated and indicated by gesture in discussion that they were ‘happy’ with the standard of furnishing and comfort in the home, and they were content with their bedroom accommodation. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 18 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) 34 and 35. The home’s recruitment and vetting procedures are evidenced as sound and the home has a positive regard for enabling staff to attend training courses. EVIDENCE: The home has a recruitment policy and procedure. The personnel file of the one member of staff appointed since the last inspection were examined. The file held all required details including: person specification, supervision records, evidence of training and certificates, learning/induction programme, probationary period report, driving documentation, application form, interview notes and written test, copy of birth certificate, photograph, passport identification and Criminal Record Bureau check. There was evidence of staff training in the areas of vulnerable adults, medication, first aid, fire protection and manual handling. The home’s manager stated that she is due to complete NVQ level 4 and The Registered Managers Award in September 05. Two staff are currently undertaking NVQ level 2 training and another member of staff has such training planned in the near future. All new staff are subject to 6 months induction training. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 19 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) 39 and 42. The home has a clear regard for health and safety matters and has a commitment to monitoring the service provided. EVIDENCE: The home’s Health & Safety policy was available. The home’s Health & Safety ‘Law’ poster was prominently displayed. The home had a current fire risk assessment dated 30th October 04. There was recorded evidence of quarterly fire evacuation drills and weekly fire alarm tests. Fire equipment and lighting tests were also evidenced. The home had current certificates for the testing of electricity, gas, hot and cold water outlets and Legionella. A record of hot water temperature checks was also available. The home’s accident record book evidenced that only one minor accident had occurred since the last inspection. No safety hazards were observed during the inspection. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 20 The home has introduced a pictorial questionnaire for the residents and their families in order to assist in the internal quality assurance system. Samples of the questionnaires were inspected and evidenced satisfaction and praise for the service. The manager monitors the home’s records on a regular basis. Regulation 33 visits occur and reports on the visits were available. The manager stated that the organisation has obtained this year’s insurance cover and the home is awaiting its current insurance liability certificate from the organisations head office. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 21 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 4 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 56 Chart Lane Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 22 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 24.1 Regulation 23,2 (o) Requirement That the organisation recruit a gardener in order that staff can consentrate on professional and resident centred aspects of their role. Timescale for action 20 / 8 / 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. 1. Refer to Standard 6 Good Practice Recommendations That the home delete the heading mood swings from the care plan format and record these areas under the heading emotional/behavioural development. 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 23 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 56 Chart Lane H58 H09 S13520 56 Chart Lane V224014 020605 Stage 4.doc Version 1.30 Page 24 - 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!