Inspection on 12/05/05 for 72 Doods Road

This inspection was carried out on 12th May 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

72 Doods Road 23/02/09

72 Doods Road 18/07/06

72 Doods Road 29/09/05

72 Doods Road 19/08/04

72 Doods Road 05/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Doods Road 72 Doods Road Reigate Surrey RH2 0NW Lead Inspector Kenneth Dunn Unannounced 12/05/05 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. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Doods Road Address 72, Doods Road Reigate Surrey RH2 0NW 01737 244177 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) Prospect Housing Association Ltd To be confirmed Care Home 8 Category(ies) of MD - Mental Dissorder 8 registration, with number of places MD(E) - Mental Dissorder 8 Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 3. The age/age range of the persons to be accomodated will be : OVER 30 YEARS OF AGE 4. The total number of 8 (eight) sevice users may be made up of a combination of people in the category MD or MD(E) Date of last inspection 19th August 2004 Brief Description of the Service: The home is a large semi-detached house located in a residential area of Reigate in Surrey. The home is served by public transport and all major routes to motorways are easily accessible. The local amenities are within walking distance from the premises. There is limited visitors’ parking although the nearby streets can also be used for additional parking. The home has a large rear garden and offers single occupancy to 8 service users. The home is run by Prospect Housing Association Limited who are the registered providers. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the home’s first inspection for the year 2005/2006 it was also the first inspection by this inspector to this home. This was an unannounced visit, which meant that staff and residents were not aware that it was due to happen as a result only 3 service users were present during this inspection. The Inspectors spent the first part of their visit in discussion with the manager and staff, checking the shared parts of the home and looking at care plans and reports. Care and health plans were found to provide a good level of information about each individual, based upon a good assessment of their needs and aspirations. One service users was able to talk about his enjoyment in living at the home, which was a great bonus for the manager and staff as the inspector was informed that he normally avoids conversations with people he does not know. The two other service users who were in the home during this inspection preferred to remain in their bedrooms and did not wish to talk to the inspector. This demonstrated that the service users were free and able to express choice and not have to comply if the did not feel like it. What the service does well: What has improved since the last inspection? What they could do better: The home was generally found to be working to a good standard, where recommendations have been made they can be found on page 23 of this report. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 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. Doods Road H58_s13533_Doods Road_120505_stage4.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 Doods Road H58_s13533_Doods Road_120505_stage4.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) 1, 2, 3 & 4 The home was operating effectively in respect of these standards. The home issued contracts to service users detailing their rights and responsibilities. The admission process is thorough and involved many parties to ensure the process is gradual and inclusive. The care notes were maintained and contained a good range of relevant updated information about each service user. The organisation is committed to ensuring that the service users are fully briefed about their rights and these rights are clearly visible throughout all of the home documentation. EVIDENCE: The statement of purpose and service user guide were easy to read and understand. They had recently been updated and the manager explained that both documents are regularly updated to ensure that they continue to reflect the home and to ensure that they meet the needs of all of their service users. The service users files sampled contained comprehensive assessments of needs, these were all carried out by the manager in conjunction with other professional parties under the auspices of a multi disciplinary review. The care notes gave clear concise and practical information in the handling of individuals and their care needs. There was a strong indication that the manager was fully aware of the individual aspirations and needs of the service users. In one case the manager stated that she had worked with a service users for over 20 years, it was clear from observation that there was a strong bond and understanding between them both. Doods Road H58_s13533_Doods Road_120505_stage4.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, 7, 8, 9 & 10 Evidence gathered from this inspection indicated that each of these standards was being met effectively. This gives confidence that each individual’s needs and aspirations were being recognised and met. There is a positive atmosphere at this home with the service users fully aware of the own needs and their individual choices for the future, either inside of the service or within the community. EVIDENCE: The files reviewed by the inspector identified that service user plans were person centred and comprehensive. These were regularly reviewed, the manager explained that they conduct monthly reviews and that all service users receive annual multi disciplinarily review it is expected or encouraged that all service users participate in their own care review and where appropriate service users or their representatives had signed the document in agreement. The manager and staff explained that they understood the rights of service users whom they encouraged to run their lives as independently as possible, within the framework of their risk assessments and their Care Programme Approach. The inspector saw evidence of extensive risk assessment on all aspects of the service users daily lives they gave clear and concise instructions for the reader to follow if an incident occurs. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16 & 17 The home meets each of the assessed standards. The manager was able to demonstrate that residents were encouraged and supported to lead as independent and fulfilling life as they were able. Activity programmes were varied and designed to meet individual needs. Links with the families, friends and the local community are good. EVIDENCE: Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 11 Service users have good access the local community facilities the manager has completed a full set of risk assessments to ensure that within limits, the service users are safe when out in the community. The manager stressed that the service users can either independently or with the support from staff and family gain access to all community based activities like clubs, bars, shops & cafes. Some service user are able to regularly attend the community day centres evidence of the programmes accessed by the service users is contained within their individual care plans. Friendships are encouraged and staff will ensure that the service users are encouraged to invite friends to their home. The manager informed the inspector that one ex-resident who now lives independently in the community regularly visits her friends at Doods Road and eats with the group and is still considered an active member of the home. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 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 standard(s) 18, 19 & 20 The residents of 72 Doods Road are encouraged and supported to lead as independent and fulfilling life as they were able. The staff remain discreetly in the back, it is not their role to act on behalf of a service users but rather to be a helping hand if the need arises. EVIDENCE: Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 13 The relationship between service users and staff was observed to be relaxed and friendly, creating a warm and homely feel. Service users were encouraged and supported to be as independent as they were able and they all appeared to lead busy and interesting lives, on the day of this inspection only 3 service users remained at the home the other were attending day care, leisure activities, shopping and one was taking part in the organisation Quality Net Work meeting (which is a forum set up to analyse and audit the care provided throughout the organisation care homes). Service users files reviewed stated that they were registered with a general practitioner. The manager stated that the staff ensured that service users received the support they needed to obtain a complete package of care. The policy for storage and handling of medication was seen, it was detailed and complied with the National Minimum Standards. The manager had compiled a comprehensive set of risk assessment to minimise the possibilities of mismanagement of medication by those service users how were self medicating. At the time of this inspection all but two of the service users were described by the manager as self-medicating. The inspector reviewed clear guidelines clearly outlining the homes medications policy. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 14 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 & 23 The home has satisfactory policies and procedures in place for dealing with concerns, complaints and protection of the Residents. The manager was able to demonstrate that service users were being appropriately protected and that their views were important and acted upon both locally and organisationally. EVIDENCE: The complaint procedure inspected was compliant with statutory requirements, the manager stated that every service users is given a copy and they are encouraged to take any issue they have to staff. The inspector was unable to verify this at the time of this inspection. Complaint forms were available for recording complaints. Records seen demonstrated there had been no formal complaint received by the home or the regulator within the last twelve months. As previously stated on page 15 of this report the organisation is very committed to the notion of the protection of and ensuring that the rights of there service users are upheld. The inspector was informed by the manager that service users are encouraged to participate in the Quality Network meeting held regularly to obtain their views and to raise any complaints in an open and regulated arena. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 15 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, 27, 28, 29 & 30. The home meets each of the assessed standards and provides a good level of accommodation, which is appropriate to the needs of the current service users group. The standard of the environment within this home is good and provides Service Users with an attractive and homely place to live. EVIDENCE: The home is spacious, comfortable clean and free from odours. The furnishing, fitting and equipment are of satisfactory quality. None of the Residents have a physical disability therefore no adaptations have been necessary. The inspector was unable to access service users bedrooms during this inspection because all of the service users were out or in bed. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 16 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) 31, 32, 33, 34 & 35 The staffing arrangements in place were sufficient to meet the needs of the service users. Staff in the home have a good understanding of the needs of the Service Users and are appropriately supported by the manager on a regular formal and informal basis. EVIDENCE: On the day of the Inspection the one member of staff on duty was observed to be undertaking a number of roles including working with the Service Users and escorting him to the Quality Network Meeting. The member of staff stated that there was a good support systems in place at the home for staff supervision and development. The relationship between service users and staff was observed to be relaxed and friendly, creating a warm and homely feel. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 17 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) 37, 38,39 & 40 There is good leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. The manager is fully aware of the needs of the Service Users in the home and as such is able to communicate this to staff through regular staff meetings and individual supervision sessions. EVIDENCE: Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 18 The manager has only just been appointed to her post however she has had many years of working with at this service and has known some service users for over 20 years. Regulation 26 (Monthly visits by the proprietor) are undertaken and evidence was seen of their occurrence. The inspector reviewed relevant policies and procedures furthermore systems were in place to ensure that these had been communicated to staff the staff sign a date all policies to indicate that they have read them. Also there is evidence in the service users meeting minutes that those of relevance to service users had been shared with them. Records examined included; care plans, medication procedures, staff & service user meeting minutes, risk assessment policies and service user activity programmes. They were seen to be in good order. There were policies and procedures in place for the health, safety and welfare of service users and staff. The manager is still to apply to the CSCI for registration, which she was in to process of and assured the inspector that her application would be with the CSCI by the end of May 2005. Doods Road H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 19 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 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Doods Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x x x H58_s13533_Doods Road_120505_stage4.doc Version 1.30 Page 20 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 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. 1. 2. 3. Refer to Standard YA22 & 23 YA33 YA1 Good Practice Recommendations It is recommended that the manager introduces a system to record all concerns raised by the service users and not just the complaints. It is recommended that the manager access the Residential Forum staffing matrix in relation to staff and service users needs. The manager to review the current service user categories and applies to the CSCI for a variation as per the discussion during the inspection. 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