Inspection on 11/07/06 for 64 Brighton Road

This inspection was carried out on 11th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

64 Brighton Road 27/10/05

64 Brighton Road 23/06/05

64 Brighton Road 25/10/04

64 Brighton Road 15/07/04

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

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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 Brighton Road (64) 64 Brighton Road Horley Surrey RH6 7HT Lead Inspector Kenneth Dunn Unannounced Inspection 11th July 2006 10:00 Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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 Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brighton Road (64) Address 64 Brighton Road Horley Surrey RH6 7HT 01293 822891 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) The Avenues Trust Limited Richard Huggett Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 32-65 YEARS One (1) named person may be aged over 65 years. Date of last inspection 27th October 2005 Brief Description of the Service: 64 Brighton Road is a registered care home for five adults with moderate to severe learning disabilities. The Metropolitan Housing Association and run by the Avenues Trust, a private company with charitable status, own the property. The building is detached. Communal facilities comprise two lounges and an open plan kitchen and dining room area on the ground floor. Five single bedrooms and two bathrooms are located on the first floor. Outside there is a large enclosed garden to the rear of the property. The home is set off the main Brighton Road with parking spaces at the front. It is close to the facilities of Horley town centre and transport links are nearby. All the service users living at the home are currently male Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for 64 Brighton Road for the inspection year 2006 and 2007. It brings together the cumulative assessment, knowledge and experience of service provision at the home over the past 12 months. This was an unannounced inspection carried out by Mr Kenneth Dunn regulation inspector and Mr Richard Huggett service manger. A partial tour of the premises took place, staff and service users were spoken to, and care records and documents were inspected. Some service users living at the home have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. There is good evidence that the care staff have a sound working knowledge and understanding of how the home operated and demonstrated a willingness to assist the service users in their daily lives. The inspector would like to thank the staff on duty and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The service has failed to meet requirements set 23 June 2006 the physical condition of areas within the home are still poor and in need of much needed general refurbishment. Work has commenced on some areas and this has made the service more homely. The kitchen is in need of urgent Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 6 refurbishment and the rear garden must be made safe by the removal of clutter and any unsafe structures. Please see requirements on Page 25. 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. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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 Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide required some updating. All potential service users are assessed using multidisciplinary assessments in order to allow the manager to identify and respond to the needs and aspirations of service users. Service users have a statement of the terms and conditions of their residency setting out individual rights and responsibilities. EVIDENCE: The inspector reviewed the statement of purpose, which details the service provided to service users. However it is in need of updating to ensure that all relevant details of the staffing and management structures and qualifications are fully documented. There has not been a new admission into the home since these documents were previously updated. In addition the service user guide should be reviewed and updated and the service users and their representatives should be provided with a copy. Please send an updated version of the statement of purpose and service users guide to (CSCI) to be held on file. Personal Care plans (PCP’s) were well documented and are undergoing a full review. However, the documents in day-to-day use are very unwieldy and need to be divided to enable staff to use as a working tool. There was clear evidence that the service users and their representatives are involved in the Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 9 design and development of the PCP’s but there was still a need for various assessment sheets to be signed and dated by the people involved in there implementation. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include in depth risk assessments. EVIDENCE: The manager has appointed one of the senior members of staff to complete a full review of all care plans and to develop a Personal Cantered plan (PCP) for each service users currently living at the home. The member of staff undertaking this task informed the inspector that the intention was to has the programme of review and the final PCP in place and operational by September 2006. It was stated by members of staff that the service users are supported to make decisions affecting their lives in a number of ways. Each service users has an allocated key worker, who is trained to offer one to one support and who is expected to develop a good working relationship with them in order to help understands their needs. In addition one member of staff stated that this system helps them develop new areas to help expand the experiences of the service users. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 11 Service users meetings are held to enable them to make decisions and choices on various areas, holidays, menu planning and outings. Staff advised that information is provided to the service users to assist with decision-making and this is in a format to suit their individual needs. Information is provided in makaton, pictorial or visual formats and staff also give information verbally, as appropriate. Information is displayed and provided for service users in picture form on a notice board in the office. The manager conducts risk assessments on all activities. Risk assessments are completed and contained within the individual service users files. However the system of storage of the risk assessments made it difficult to fully gage the risk and to develop an overall picture of risks assessed. It is recommend developing a risk assessment folder in order to prioritise assessed risks ensuring that there is a clear paper trail directing the reader to the full assessments. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that residents’ rights are respected. EVIDENCE: Staff stated that they actively encourage and support the service users to be independent, to make their own choices and to live their lives as they wish, as far as they are able. The general household and domestic routines are kept to a minimum and are only in place to enable the service users to share their home’s facilities and to maintain harmony within the household. In addition a member of staff stated that they knock before entering a service users private bedrooms and that personal care is offered discreetly. Service Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 13 users were addressed in the way that they prefer and this is recorded in their individual plan. The service users are supported by staff to maintain and develop links with their family and friends this is achieved by regular telephone call are during times of review. The manager explained that on a regular basis relatives are invited to attend meetings to discuss any issues or pending arrangements for example holidays and activities. All service users have a holiday once a year. At the time of this inspection two service users were away on holiday with staff to a cottage in Derbyshire, the previous week two were in Devon. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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): 18. 19 & 20 Quality in this outcome area were good. This judgement has been made using available evidence including a visit to this service. Personal care, healthcare support and any additional forms of assistance are planned and were seen to be provided, where needed, in a respectful and sensitive manner. Sound policies and practices are in place for the administration and management of medication. EVIDENCE: The system for medication administration was seen and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets were seen and no gaps in the recording were noted. The CSCI had been notified of an incident involving an error with medication, the manager sought immediate medical advice and assistance and it was recorded that the service user was not at risk from this error. The manager stated that since then the issues has been addressed with the staff members involved and as a result the members of staff have been retrained and the manger has also reviewed the risk assessments to ensure they establish clear protocols for the administration of medication. A photograph of each service user is provided with the MAR sheets to guide staff to the correct service user and a medication information sheet gives details of the medications for each. No service users self medicates the manager has completed risk assessment to support this. However the risk assessments should be stored in one Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 15 consistent area within all the service users files on the day of the inspection they were filed in differing sections of each SU. Service users were registered with a general practitioner (GP). The manager confirmed that health care action plans were being further developed as part of the person centred plans being implemented. The senior member of staff completing the process of updating all PCPs stated that the completion of this would be by the end of September 2006. The manager should develop contact sheets to indicate where notes are when removed from the file, contact sheets. The home operates within the requirements of the trust medication policy no service user self medicate. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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): 22 & 23 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: The service has a solid and robust complaints policy, which is contained within the Service User guide and the employee’s handbook. The service users are well protected by the Avenues employment practices. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there have been no complaints made directly to the service or to the Avenues since the previous inspection. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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, 25, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and relatively well maintained. The home was found to meet the service users individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were found to be clean and hygienic, all staff to be congratulated on the cleanliness of the homes. The service users have their own bedroom and these had been made personal with pictures and posters, some have televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size. It is pleasing to see that each room is individually decorated and residents are supported to choose the colour schemes to suit their preferences. The stair carpet was badly worn and frayed and has to be considered a trip hazard especially as one of the service users has recently been registered with a visual impairment. The carpet therefore must be replaced immediately. The rear garden was over grown and contained several discarded household items in addition there were two dilapidated structures, which could pose a risk to the service users. The garden must be tidied up urgently with the removal Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 18 of the old greenhouse; garden waste and patio areas are immediate requirements. This is now a requirement, which has been in place since 23 of June 2005 the manager must now take immediate action to remedy this situation, as failure to take action may result in enforcement action. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual residents at the home. Staffing is kept under review and provided to meet the needs of the residents at all times. EVIDENCE: It was pleasing to note that staff have a good understanding of the residents needs, are respectful and have a good rapport with the service users. Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. It is recommended that the registered manager to ensure all staff have a copy of the General Social Council & Care, code of conduct document. Two members of staff have completed NVQ Level 3 and a further two member of staff has nearly completed NVQ Level 3. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. A number of training courses have been undertaken and all new staff receive an induction programme, which is covered over six months. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 20 Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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): 37, 39, 40 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach in the home provides an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the residents. EVIDENCE: The manager has recently been registered by CSCI. Since being appointed as manager to the home a lot of work has been accomplished to ensure the home is meeting the required standards and regulations. The registered manager has undertaken the Registered Managers Award and is currently undertaking the NVQ level 4 in care should be completed by the end of summer 2006. The home has an effective quality audit monitoring system in place. The service manager completes a regular monthly regulation 26 notification visit and the report is well documented. The records observed on the day of the site visit were found to be well documented and kept up to date. This included certificates for the testing of Legionella, gas, electrical and a number of other areas tested. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 22 The manager has made repeated attempts to meet the requirements made during the previous inspections and all requirements within the remit of the manager to complete have been successful. However there were to considerable outstanding environmental requirements that have been ongoing since the inspection year 2005/2006, it is essential that all requirements are met as failure to do so may result in future enforcement action being taken against the registered provider and the registered manager. Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4, 5 & 6 Schedules 1, 4.1, .2 Requirement The statement of purpose must be update to ensure that all relevant details of the staffing and management structures and qualifications are fully documented. The service user and their representatives should be provided with a copy of the updated statement of purpose and user guide. An updated version of the statement of purpose and service users guide must be sent to (CSCI) to be held on file. The stair carpet was badly worn and frayed and has to be considered a trip hazard. The carpet therefore must be replaced immediately The rear garden was over grown and contained several discarded household items in addition there were two dilapidated structures, which could pose a risk to the service users. The garden must be tidied up urgently the removal of the old greenhouse garden waste and DS0000013526.V302168.R01.S.doc Timescale for action 30/09/06 2 YA1 4, 5 & 6 Schedules 1, 4.1, .2 30/09/06 3 YA24 16.1,23.1 & 23.2 11/07/06 4 YA24 16.1,23.1 & 23.2 11/07/06 Brighton Road (64) Version 5.2 Page 25 patio areas immediate. 5 YA24 16.1,23.1 & 23.2 The kitchen is in need of urgent and essential refurbishment. 11/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA9 Good Practice Recommendations It is recommend developing a risk assessment folder in order to prioritise assessed risks ensuring that there is a clear paper trail directing the reader to the full assessments. The risk assessments should be stored in one consistent and easily accessed area within all the service users. The manager should develop contact sheets to indicate where notes are when removed from the file, contact sheets. It is recommended that the registered manager to ensure all staff have a copy of the General Social Council & Care, code of conduct document. 2 3 YA9 YA40 4 YA31 Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brighton Road (64) DS0000013526.V302168.R01.S.doc Version 5.2 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. 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