Inspection on 18/07/06 for 72 Doods Road

This inspection was carried out on 18th July 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

72 Doods Road 23/02/09

72 Doods Road 29/09/05

72 Doods Road 12/05/05

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) 72 Doods Road Reigate Surrey RH2 0NW Lead Inspector Kenneth Dunn Unannounced Inspection 18th July 2006 10:00 Doods Road (72) DS0000013533.V302174.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 Doods Road (72) DS0000013533.V302174.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. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Doods Road (72) Address 72 Doods Road Reigate Surrey RH2 0NW 01737 244177 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) Prospect Housing and Support Services Lesli Margaret King Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (8) Doods Road (72) DS0000013533.V302174.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: OVER 30 YEARS OF AGE The total number of 8 (eight) service users may be made up of a combination of people in the category MD or MD(E). 29th September 2005 Date of last inspection 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 (72) DS0000013533.V302174.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 72 Doods 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 Ms Josefina Jose Senior Support Worker represented the service. 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 challenging behaviour 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: 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 (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 6 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 Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 7 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 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are good providing service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for assessing needs are strong ensuring service users need are assessed and identified prior to admission to the home. EVIDENCE: The service user Guide and statement of purpose are well designed and have been developed with the specific needs of the service users and it appears to fully meet their individual and joint needs. There is clear evidence that these documents have been reviewed and updated recently. There has been no new service users admitted into the home since the previous inspection by the CSCI. The policy in operation for potential service users fully reflects the prescribes procedures established by the National Minimum Standards, which requires all of the individuals needs to be assessed by a trained member of staff to ensure that the home can meet their individual needs and aspirations. Prospect Housing Association have very robust procedures governing potential service users they must be given the opportunity to test-drive the home; to ensure that they are suitable for the home and that the home is suitable for Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 8 them. The policy, procedures and guidance to the manager and staff are fully compliant. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning at the home are good ensuring service users assessed needs are reflected in their care plans. The systems for decision making at the home are very robust ensuring service users are supported to make decisions about their lives. Risk taking policies are good and risk assessments are carried out on all activities. EVIDENCE: The home has care plans drawn up with the involvement of service users together with their relatives, care staff and other professionals. The care plans are reassessed monthly, risk assessments 3 monthly, full review 6 monthly, this is flexible this can be brought forward if a change is detected. All service users have one full review of their needs annually. The home has a key worker system, which is regularly reviewed. The inspector noted a service user who displayed behaviours that challenge the service had a specialist behavioural assessment to enable staff to support the service user in question consistently and safely. The home involves service users in decision making, which is reflected in the care plans. The service users are encouraged to make their own decisions the inspector was informed that staff would only assist if they were asked directly Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 10 or if the member of staff knows a service user is struggling they will offer to help. The home has a policy of risk taking and risk assessments are in place for all service users. The service users are actively encouraged to be as independent as possible risk assessments are completed by the individual key workers and agreed by the manager. Observations confirmed staff provided service users with information to make decisions about their own lives. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 15 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports service users to take part in valued and fulfilling activities. The arrangements at the home enable service users to be part of the local community. The policies and routines at the home promote personal relationships with families and the rights of service users. Meals at the home are good offering both variety and choice EVIDENCE: The service users attend various day centres, and many are involved in the local community activities. All of the service users are involved in jobs around the house these include cooking, emptying the bins, putting their clothes away and gardening. Most of the service users like to go shopping; this is undertaken with their key worker or some will go out on their own. One service user works for a charity “Helping Hands” this is a locally based service for general light DIY in the communities there is no payments for this service referral based. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 12 The home has its own transport to enable service users to access community facilities and the inspector noted service users were supported by staff to use public transport to access shops, pubs, cinema and other places of interest. The home support service users to maintain family links and friendships and the inspector noted relatives visited service users at the home regularly. Observations confirmed service users had unrestricted access in the home and staff supported service users in maintaining their independence. The home has a written weekly menu plan and a record of meals eaten by service users. Service users are involved in planning the menu and in the preparation of meals. The service users are expected with the assistance of staff to cook for the group at least once a week. The menus reviewed look varied and wholly appropriate for this group. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 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 the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring service users are supported in the way they prefer. The arrangements in place for meeting the health care needs of service users living at the home are appropriate. Medication management at the home is good and promotes the health of service users. EVIDENCE: The inspector was informed that the service users are very independent and require little assistance if any in respect of their personal support. It was observed throughout the inspection that the service users were perfectly capable of undertaking their own personal care needs. The policy of the home is to support, maintain, and develop and ultimately to assist the service users to become as independent as they are capable. The inspector was informed that the home always defers to and seeks assistance from external professionals in respect of the needs of the service users. Service users are supported in a way that promotes their privacy and dignity. Service users preferences about personal support are recorded in care plans and observations confirmed staff supported service users to maintain their independence in choosing clothing, meals and activities. The service users have access to a GP, dentist, optician and chiropodist to maintain good health. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 14 The home has a robust policy on medications. Out of the eight service users living at 72 Doods Road six are self-medicating and risk assessments have been carried out to ensure that the service users are safe. The risk assessments are reviewed 3 monthly the inspector was informed that this can be more frequent if there is a justifiable reason to do so or there is a change in the individuals behaviour pattern. The key workers are expected to supervise weekly the service users making up their own Dosseet boxes, which are stored in lockable cabinets in the individual’s bedrooms. The two remaining service users are fully assisted by staff to take their medication. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 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 the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process at the home is satisfactory with complaints information available to staff, service users and relatives. The arrangements for protection are satisfactory ensuring service users are safeguarded from abuse, neglect and harm. EVIDENCE: The home has a complaints policy, which is contained within the Service User guide and the employee’s handbook. The service users are well protected by the provider’s employment practices. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there has only been one complaints made to the manager since the previous inspection. A review of the complaint indicated that it was fully resolved by the manger and the complainer was satisfied. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 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 the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems for managing the premises are arranged to ensure that the service users live in a homely and comfortable environment. Bedrooms are of a suitable size and layout promoting the independence of service users. The arrangement for hygiene and control of infection is good ensuring the home is clean and hygienic. EVIDENCE: On the day of the inspection the home was clean, well presented and free from mal odour. The standard of décor was generally good throughout the home. The gardens were well maintained and the inspector. Bedrooms were decorated in a fashion that suits the individual service user occupying the room they are reasonably well presented and personalised. Furnishings and fittings were of a good quality and were in sufficient numbers to allow the staff and service users to socialise. Staff had training in infection control and observations confirmed staff practised infection control measures by washing their hands regularly. The home kept a record of repairs and maintenance to the home with appropriate management action taken. The registered provider continues to conduct monthly Regulation 26 sites visits to ensure that the home is meeting with the National Minimum Standards. The inspector has reviewed these documents and they offer a true and accurate picture of the home. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 17 Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 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: The relationship between residents and staff was observed to be relaxed and friendly, creating a warm and homely feel. Residents were encouraged and supported to be as independent as they were able. The registered provider has developed a set of robust employment policies and procedures. The inspector was informed that they are under continual review to ensure that they accurately reflect the working practices of the home and fully with current legislation. The organisation is working towards Investors in people award this has been actioned since Dec 2005. Prospect Housing Association has a strong commitment to the continued training and development of its staff. The manager maintains a training matrix, which highlights the training strengths and weakness of the staff team. The inspector was informed by the head of Mental health and Domiciliary Services that staff training outcomes are monitored once a month by the manager this then discussed with the her line manager to ensure that the home is staffed effectively. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 19 Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 20 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 & 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 home appears to be well managed the policy and practise is to be open and to provide and all encompassing environment, which is positive and inclusive. The home has an effective quality audit monitoring system in place. The service manager (Mental health and Domiciliary Services Manager) completes a regular monthly regulation 26 notification visit records were seen and are fully reflective of the service. In addition the service conduct open and well-documented house meetings monthly where any issues the service users Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 21 and staff have can be raised and effectively dealt with or channelled an appropriate person if it is out with the remit of the manager. The home has just undertaken a full Quality audit of the service this was completed by the service users and the inspector was informed that the results were very favourable. The inspector was not able to review the results for himself at the time of the inspection, as they are stored at the main office of the registered provider. The manager must ensure that a copy of the survey should be readily available for future inspections. 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. PAT testing, Food Hygiene and a number of other areas tested. Insurance cover for the home is in place. The home has a business and financial plan developed by manager; Prospect Housing Association devolves the budget to the managers to allow the home to be as autonomous as possible. Prospect Housing Association finance department monitors the budget for the home in conjunction with the manager and service manager to ensure that the home maintains its financial viability. Records are maintained to a high level. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 X 4 3 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 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 2 X X 3 X Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 23 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 YA39 Regulation 24 Requirement The manager must ensure that a copy of the survey should be readily available for future inspections. Timescale for action 30/09/06 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. 2. 3. 4. Refer to Standard YA22 YA33 YA1 YA23 Good Practice Recommendations It is recommended that the manager introduce 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. It is recommended that the manager introduce a system to record all concerns raised by the service users and not just the complaints. Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 24 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 Doods Road (72) DS0000013533.V302174.R01.S.doc Version 5.2 Page 25 - 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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