Inspection on 27/10/05 for 64 Brighton Road

This inspection was carried out on 27th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

64 Brighton Road 11/07/06

64 Brighton Road 23/06/05

64 Brighton Road 25/10/04

64 Brighton Road 15/07/04

Similar services:

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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 Brighton Road (64) 64 Brighton Road Horley Surrey RH6 7HT Lead Inspector Kenneth Dunn Unannounced Inspection 27th October 2005 10:45 Brighton Road (64) DS0000013526.V259347.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 Brighton Road (64) DS0000013526.V259347.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. Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 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 To be confirmed Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 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 23rd June 2005 Brief Description of the Service: 64 Brighton Road is a registered care home for five adults with moderate to severe learning disabilities. The property is owned by the Metropolitan Housing Association and run by the Avenues Trust, a private company with charitable status. 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.V259347.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the home’s second inspection for the year 2005/2006. This was an unannounced visit, which meant that staff and residents were unaware that it was due to happen. The atmosphere in the home is warm and friendly; this helps the service users to know and understand that this is their home. The Inspector was informed that service users are supported in a positive way to make choices and enjoy their chosen activities. Routines in the home are flexible and Service users make choices about how they wish to spend their time. However the overall environment of the home was poor and requires considerable impute to ensure the benefit from a clean and safe place to live. What the service does well: What has improved since the last inspection? What they could do better: The physical condition of the premises is poor and in need of much needed review and possibly a complete general refurbishment. The kitchen is in need of urgent refurbishment and the communal lighting in all areas of the home is very poor and unsuitable. The manager must also review staffing specifically loan working the house is situated in the community but it is physically isolated from the adjacent properties and if a situation arose it would be difficult to attract attention until more staff returned to the house. Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 Page 6 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.V259347.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 Brighton Road (64) DS0000013526.V259347.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): Standards 1 & 2 were assessed on the last inspection. EVIDENCE: For information on these standards please refer to the report of 23 June 2005. Brighton Road (64) DS0000013526.V259347.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): 6&7 Evidence gathered from this inspection indicated that both of these standards were being met effectively, indicating that individual’s needs and aspirations were being recognised and met. EVIDENCE: All of the service users have now had a full review of their individual and group needs, it was felt that 64 Brighton Road was still effectively meeting their needs. The inspector was informed by the staff member on duty that “they discuss with the service users what they want to do, but that they must also refer to past knowledge of the service users to make a full picture of the situation”, to ensure that the service users can make the most appropriate decisions. Brighton Road (64) DS0000013526.V259347.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): 15 & 17 The service users are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that service users’ rights are respected. The service has sought professional assistance to ensure that meals are appropriate and healthy. EVIDENCE: Staff support service users to maintain family links and friendships inside and outside the home, this may involve family members or friends being invited to participate in meals, or enabling the service user to visit the family home. There are no restrictions to visiting and service users can see visitors in the privacy of their own rooms if they wish. All interactions observed between the staff and service users were seen to be respectful and caring. A copy of the planned menu was seen as part of the inspection process this indicated that personal preferences had been taken accounts and demonstrated that where specialist needs and assistance was required they had been sourced. Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 Page 11 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): 20 The health needs of the Service Users was being met effectively, there was evidence of consultation with other professionals taking place on a regular basis. EVIDENCE: There is a robust set of medication policy and procedures in place. Avenues Trust Limited has procedures setting very specific measures to be followed when handling and dispensing medication. The medication is stored securely in a locked cabinet in the office. No Service Users currently administer their own medication. Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 Page 12 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 All required policies and procedures are in place to ensure that service users feel their views will be listened to. EVIDENCE: The complaint procedure was compliant with statutory requirements. Complaint forms were available for recording complaints. Service Users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. Up to date training in the Protection of Vulnerable Adults is in place and is part of the company’s ongoing commitment to staff training. At the time of this inspection there had been no complaints received by CSCI in relation to this service. Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 Page 13 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, 26, 27, 28, 29 & 30 The overall standard of décor and equipment in the home was poor. Some effort has been made to surface clean the home the general environment internally and externally was not satisfactory. EVIDENCE: The inspector discussed in detail with the member of staff on duty the areas within the home that require immediate attention and were of an unacceptably poor standard. Generally the home was shabby and requires a full spring clean. The light fittings throughout the building must be reassessed, on the day of the inspection ceiling paper lanterns were not fitted correctly and were touching the light bulbs and could therefore be considered a fire hazard. The lighting in general must be reviewed in order to minimise the shadows and dark areas in the home. The carpets in the rooms inspected were all heavily stained. The kitchen must be reviewed to ensure that is offers a safe and homely environment for the service users and staff to use. Externally the front garden area is unkempt and used as a vehicle turning area as a result the lawn has been damaged. The manager must ensure that an inspection of the exterior walls is completed; this was highlighted by the possibility of damp in the dining room, which may be occurring due to water penetration. The patio area, which was subject to a requirement from the inspection dated the 23rd of June 2005 is still outstanding. Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 Page 14 The manager must develop an action plan for a process of deep cleaning throughout the home. In addition the manager must ensure that an appropriate professional to ensure that it is safe and water resistant must assess the exterior of the house. One service user had been assessed to hold his own key to his bedroom however because of the poor maintaince of the house this has not been actioned as the door does not fit the surrounds and has made the use of a key academic. Brighton Road (64) DS0000013526.V259347.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): 33, 34 & 35 The interactions observed between the member of staff on duty and the service users evidenced a good degree of respect and skill in working with the individual service users at the home. EVIDENCE: The manager of the home was not on duty, which resulted in the inspector being unable to review staff records, and therefore the requirement from the previous inspection will be carried over. At the time of this inspection only one member of staff was on duty with two service users. The member of staff assured the inspector that she was in a good position to provide care for the service users she was assisting that morning. However the manager must review the policy of loan working and ensure that the safety and security of both service users and staff is not jeopardised by this practise. Brighton Road (64) DS0000013526.V259347.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): Standards 37, 38, 39 & 42 were assessed on the last inspection. EVIDENCE: For information on these standards please refer to the report of 23 June 2005. Brighton Road (64) DS0000013526.V259347.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 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 1 1 1 1 1 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brighton Road (64) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000013526.V259347.R01.S.doc Version 5.0 Page 18 YES 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 YA24.1 Regulation 16 (1)(g) Requirement Timescale for action 27/10/05 2 YA24 3 4 YA30 YA25 5 6 YA30 YA28 7 YA24 It is required that the kitchen is refurbished as soon as possible. Please provide an action plan for refurbishment 23 It is required that the lighting (2)(b)(c) and light shades are reviewed to (d)(p) ensure the light produced is satisfactory and the shades are safe. 13(3) The manager must conduct a full review of the systems in place for the cleaning of the home. 16(1,2)(c) Poor maintaince must not restrict 23(2)(e,f) the opportunities for key holding and use, the manage must ensure that where keys are accessible to service users the lock must operate correctly. 13, 16 & The carpets were all heavily 23 stained and require being deep cleaned if possible or replaced. 16 & 23 The front garden area must be is reviewed and altered accordingly, either hard standing for vehicle or garden. 16(1) The manager must ensure that 23(1,2) an inspection of the exterior walls is completed. 18(1)(a) The manager must review the DS0000013526.V259347.R01.S.doc 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 27/10/05 8 YA33 27/10/05 Page 19 Brighton Road (64) Version 5.0 Sch 4.6,4.7 policy of loan working and ensure that the safety and security of both service users and staff is not jeopardised by this practise. 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 Brighton Road (64) DS0000013526.V259347.R01.S.doc Version 5.0 Page 20 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.V259347.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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