Inspection on 12/01/06 for Andover Close (31)

This inspection was carried out on 12th January 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Andover Close (31) 17/12/08

Andover Close (31) 18/12/06

Andover Close (31) 24/10/05

Andover Close (31) 02/06/04

Andover Close (31) 28/02/04

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

CARE HOMES FOR OLDER PEOPLE Andover Close (31) 31 Andover Close Epsom Surrey KT19 9DA Lead Inspector Pauline Long Unannounced Inspection 12th January 2006 10:00 X10015.doc Version 1.40 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 Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 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 Older People. 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. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Andover Close (31) Address 31 Andover Close Epsom Surrey KT19 9DA 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) 01372 740251 Mr Alan Rothwell Mrs Deborah Laker-Rothwell Mrs Deborah Laker-Rothwell Care Home 1 Category(ies) of Learning disability over 65 years of age (1) registration, with number of places Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2005 Brief Description of the Service: 31 Andover Close is a four bed-roomed house, situated in a quiet residential area on the outskirts of Epsom. The home provides care and accommodation for one older Resident, with a learning disability. The resident lives as part of the family, and occupies a downstairs bedroom with an en-suite shower room. There is a sitting room for communal use, and a separate kitchen. The home also has a small-enclosed garden to the rear of the property and a paved area to the front of the house. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Inspection of the CSCI year April 2005- March 2006 and was unannounced. The inspection was carried out by one inspector and lasted for two hours. On the day of inspection the service had a homely, welcoming and relaxed atmosphere. During the inspection process, discussions were had with the resident and manager. Documents inspected, included the residents file, care plan, and the homes policies and procedures and records. A tour of the resident’s accommodation, kitchen and sitting room took place. CSCI would like to thank the resident and manager for their hospitality and cooperation during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Failure to comply with these may result in CSCI seeking legal advice, if these continue to remain unmet. The home has produced a Service user Guide and Complaints procedure. However neither of these documents reflected the current details for the CSCI. To ensure the protection of the service user, the registered person(s) must review the above documents and amend them to include details of the CSCI. This requirement was made at the previous inspection and has not been met. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 6 The armchair in the resident’s bedroom was not appropriate for her needs. In order to ensure that the resident is able to get in and out of her armchair without assistant and in safety, a new armchair must be bought. The manager must improve record keeping in respect of health and safety. Fridge, freezer and food temperatures must be recorded on a daily basis, in compliance with food hygiene regulations. The home routinely carries out checks on the fire procedures in the home, however the fire extinguisher has not been checked since it was bought. The manager must take steps to ensure the fire extinguisher is in working order. This must be checked on a checked on a yearly basis and records kept. The manager was unable to produce some of the records requested at inspection. This was a concern, as at the last inspection, these records were unavailable. In order to ensure that the resident is protected by the homes record keeping, all records must be available for inspection. 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. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4,5 Arrangements were in place to ensure a full needs assessment takes place before any new admission. The prospective resident had an opportunity to visit the home before admission. EVIDENCE: The manager had worked with the resident for many years before she was discharged from the long stay hospital she lived in. The manager stated that the resident had a comprehensive assessment of needs, before being admitted to the home. The manager commented that the resident visited the home before she was discharged from hospital. All aspects of daily living needs were assessed, indicating that the manager would be fully aware of the residents care needs. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10,11 On the day, the manager had a good understanding of the resident’s health and personal care needs. These needs were well met. Privacy and dignity were respected. EVIDENCE: The resident’s care plans were comprehensive, and included needs assessments, communication assessments, risk assessments with regard to manual handling, falls and other potential risks. The care plans were reviewed on a monthly basis. The manager was observed supporting the resident with her personal care. She ensured that the bedroom door was closed whilst she carried out the residents morning shower. Her approach and manner were respectful. There was evidence in the residents care plan and health record to indicate that discussions had been had with her around her wishes after her death. She had made a particular request around the hymns for her funeral. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 10 Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15 The manager promotes contact with family and friends and the community. The food at the home is good. EVIDENCE: The resident’s care plan, included information with regard to social, cultural, religious and recreational interests and needs. The resident referred to many outings over the Christmas period for example: shopping, a visit to a “posh restaurant” for Christmas lunch, a visit to her nephew on boxing day. The manager discussed various visits to the shops and the local library, and the resident commented, she particularly liked having her lunch there. The resident also commented that she liked the food provided at the home. Meals are eaten with the whole family. The inspector observed boxes of snacks biscuits and sweets, which were kept in the resident’s bedroom. The manager commented that these were kept there to ensure that if the resident felt peckish then she could help herself. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has satisfactory policies and procedures in place for dealing with the protection of the residents, and for addressing concerns and complaints. EVIDENCE: The home has a complaints policy and procedures. However this was developed some time ago and does not reflect up to date details of the CSCI. CSCI have received no complaints about this home since the last inspection. The manager was confident that the resident would be in a position to voice her opinions if she was not happy. On the day the resident commented that she was happy and had no complaints apart from the fact that the homes cat was a bit of a devil. The manager stated that she has attended the Surrey County Council Multi Agency Protection of Vulnerable Adult Abuse training. The home has a copy of the Surrey County Council Multi Agency Procedures manual, however it was out of date. The manager was advised at the previous inspection that she should be using the updated version ( February 2005). To date the updated version has not been obtained. A recommendation and requirements have been made in these areas. Please refer to page 24 of this report. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 The standard of the environment within this home reflects a busy family situation, and currently meets needs of the resident, providing a homely and safe place to live. EVIDENCE: It was pleasing to note that the sitting room had been cleared of all the children’s toys, providing much more space. The family are in the process of improving the resident’s accommodation. A new toilet had just been delivered, and once installed will complete the work being carried out on the residents accommodation. During the previous inspection, the manager commented that they were in the process of decorating the hallway and communal areas. To date this had not been completed, the manager was confident, that as soon as the renovation work was completed they could get on with the redecoration. The resident uses a wheelchair when outside the home and a rolling zimmer frame when inside the home. There was no evidence to suggest that either of these pieces of equipment had been serviced. The manager was advised that Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 14 these items of equipment should be routinely serviced to ensure that they are safe for purpose, and that records must be kept. A requirement was made in respect. Please refer to page 24 of this report. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection as no staff are employed at this home. EVIDENCE: Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,37,38 The resident benefits from the ethos and management approach at the home. Record keeping is satisfactory in some areas. Health and safety checks are routinely carried out, however some records were not accessible on the day. EVIDENCE: The manager’s approach was open and inclusive. From observation of her interactions with the resident it was clear that there continues to be an atmosphere of openness and respect. The resident is treated as one of the family, and a close relationship had developed between them. The resident has control over her own financial affairs, and the manager supports the resident to maintain her own bank account. The manager stated a record of all the residents financial transactions are kept, however these were not sampled on the day as again they were locked away. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 17 The home invoices the local social services team on a monthly basis for the care service provided, payment is then made to the home. On the day of inspection the manager stated that all of the years invoices were with their accountant, therefore the inspector was unable to sample these records. Record keeping in respect of care given, were satisfactory and were stored appropriately, securely and confidentially. However there was a concern that other records were not available for inspection. The manager stated that when the invoices were returned to the home, she would forward copies to the CSCI. The manager stated that health and safety checks are routinely carried out at the home. Again this could not be evidenced, as not all records were available for inspection as they were locked away. Fire alarm checks and a fire drill had been carried out on 01/01/06, the gas boiler had been serviced on the 12/12/05. A requirement has been made in respect of recordkeeping. Please refer to page 24 of this report. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X X 3 X 2 X 3 STAFFING Standard No Score 27 N/A 28 N/A 29 N/A 30 N/A MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 X X 2 2 Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP16 Regulation 5 (1(e(f) Schedule 1 Requirement The registered person(s)must ensure that the Homes, Service User Guide and Complaints Procedures are reviewed and amended to reflect the current details for the CSCI. Previous timescale of 14/12/05 not met. The registered person(s) must ensure that the resident is provided with an armchair appropriate to her needs. The registered person(s) must ensure that all equipment used in the home is regularly serviced and fit for purpose. The wheelchair and zimmer frame must be serviced and records kept. The registered person(s) must ensure that records are kept in respect of food hygiene regulations. Fridge, freezer and food temperatures must be checked on a daily basis and records kept. The registered person(s) must ensure that the fire extinguisher is checked yearly and that DS0000039293.V277819.R01.S.doc Timescale for action 12/02/06 2 OP24 12(1(a 16(2(c 13(3(a 12(1(a 23(2(c 12/03/06 3 OP38 12/03/06 3 OP38 17(1)(2)3 )(a(b Sch 4 12/02/06 4 OP38 12(1(a) 23(4(c(iv 12/02/06 Andover Close (31) Version 5.1 Page 20 5 OP37 17(1(a(b 2(3(a,b, records are kept. The registered person(s) must ensure that all of the homes records are up to date, open and available for inspection. 12/02/06 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 OP37 Good Practice Recommendations The registered person(s) should consider developing the records kept in respect of daily living activities in order to provide a more holistic view as to the resident’s day in the home. Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 21 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 Andover Close (31) DS0000039293.V277819.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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