Inspection on 18/12/06 for Andover Close (31)

This inspection was carried out on 18th December 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 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

Andover Close (31) 17/12/08

Andover Close (31) 12/01/06

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 Kenneth Dunn Unannounced Inspection 18th December 2006 09:00 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.V322438.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 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.V322438.R01.S.doc Version 5.2 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.V322438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 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.V322438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection in the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Mrs Deborah Laker-Rothwell representing the home assisted Lead Inspector Mr Kenneth Dunn throughout the inspection. The IBL process involves a pre-inspection assessment of service information from a variety of sources. Initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. The inspection of 31 Andover Close took place over a period of 2 hrs during which samples of; care assessments and care plans were inspected. All of the key inspection standards for older persons were assessed. What the service does well: What has improved since the last inspection? What they could do better: Encourage the service user to sign and own the documents that she assists to prepare. The manager needs to update her training for the protection of vulnerable adults. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 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.V322438.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements were in place to ensure a full needs assessment takes place before any new admission. Standard 6 was discussed however it does not apply to this service. EVIDENCE: The manager has worked with the service users for over 20 years. The service user came to live within this small family unit after a period of planned and regular visits. The manager stated that the service user had a comprehensive assessment of needs, before being admitted to the home and from the records seen, it was clear that the need of the service user was fully assessed prior to her being admitted to the home. The needs assessment was detailed and contained information regarding all aspects of the daily living needs of the service users The providers advised that intermediate care is not provided. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 9 Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has developed a comprehensive and individual plan of care. The service users healthcare needs are very well met and the service has a sound medication policy. EVIDENCE: The manager advised that a detailed individual plan of the care and support needs of the service user was drawn up, using the information gathered from the pre-admission assessment and past knowledge. The document seen was comprehensive, contained the required information and there was evidence that it had been reviewed regularly. An “end of life” plan is included within the individual plan and this notes who will make arrangements in the event of the death of the service user. Assessments of risks to the service user have also been carried out and these included risks in the event of a fire, moving and handling risks, mobility risks and behavioural risks. From the records seen it is clear that the service user’s healthcare needs are very well met and that any changes in her health will be closely monitored and appropriate treatment is promptly obtained. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 11 At the time of the inspection the service users was not taking any medication. The service has a robust set of policies and procedures in place to be introduced if and when medication is prescribed. The service user was seen to be treated with the utmost respect and is cared for in a friendly manner whilst retaining a professional approach. Assistance with personal care was given discreetly and in a manner that promoted residents’ dignity and privacy. The manger explained that on occasion of ill health or a period where the service users has problems sleeping the use of a baby monitor is actioned. The manager was clear in its use and explained that it is used with the knowledge and permission of the care manger and the service user’s next of kin. However it is recommended that the manager seek the permission of the service user who can readily give written permission for this practices. A recommendation and requirements have been made in these areas. Please refer to page 24 of this report. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The uniqueness of this service allows a great deal of flexibility in regards lifestyle experiences. The service user is supported to keep in touch with her family and friends. Wholesome and appetising meals are provided. EVIDENCE: The service users care plan, included information pertaining to social, cultural, religious and recreational interests and needs. The inspector reviewed documentation, which referred outings and trips the manger assists the service user to keep a diary of events and activities, which they write up every evening together. The diary makes references to recent Christmas shopping trips with the manager or on occasions as one large family group. It was discussed with the manager that the service user should be encouraged to sign all documents where it is appropriate but especially those that she has participated in completing. There is also a well-maintained meal planner, which gives a clear picture of the meals the service user has again as part of the 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.V322438.R01.S.doc Version 5.2 Page 13 A recommendation and requirements have been made in these areas. Please refer to page 24 of this report. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 and in line with a requirement from a previous inspection report has been updated and now received regular reviews. . CSCI have received no complaints about this home since the last inspection. The manager was confident that the service user would be in a position to voice her opinions if she was not happy. The manager stated that she has attended the Surrey County Council Multi Agency Protection of Vulnerable Adult Abuse training however this was in 2001 while she was still employed in the NHS. A recommendation and requirements have been made in these areas. Please refer to page 24 of this report. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The over all standard of the home is good and currently meets needs of the service user and certainly could be considered as offering a homely and safe place to live. The premises are pleasant, clean and appear hygienic. EVIDENCE: The manager stated that a programme of annual, planned improvements and renewal is maintained however the refurbishment of the home has been ongoing for some considerable time. However the areas that directly affect the service user is completed and is generally is good order. The inspector discussed with the manager the need to highlight a small step inside of the bedroom door of the service user’s. The home was fully decorated for Christmas a process the service user was very much involved in. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 16 At the time of the inspection the environment of the home was pleasant, clean and appeared hygienic. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the staffing levels meet the needs of residents. Procedures and practices are in place at the home to ensure that service users are in safe hands. EVIDENCE: The service currently employees only the manager. Discussions with the service user and general observations indicated that the service users needs are being effectively met by this arrangement. The manager has an understanding of recruitment policies and procedures and stated that she would implement them when a need arises to employ staff. In addition the manager is aware of and has investigated training packages for use within the home initially to maintain her skills but they would also be the bases of future staff training. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service benefits from the flexible arrangements for running and operating the home. The service users can enjoy a degree of spontaneity seldom available in other establishment with more service users. Record keeping has been improved in line with a previous requirement. Health and safety checks are routinely carried out, and records of all checks are now routinely updates and reviewed. EVIDENCE: The manager’s approach was open and inclusive. From observation of her interactions with the service user it was clear that there continues to be an atmosphere of openness and respect. The service user is treated as one of the family, and a genuinely close relationship was observed between the manager and her family and the service user. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 19 The service user has full control over her own financial affairs, and the manager supports her to maintain her own bank account. The manager stated a record of all the residents financial transactions are logged and updated on a regular basis. The banking records were made available to the inspector and were seen to be in good order. The health and safety of the home are well managed and of those records sampled, were appropriately maintained. Checks, including fire system servicing and food temperature testing, they have been carried out to the required frequency and were seen to be within required ranges. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 20 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 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP18 OP19 Regulation 10(1), 12, 13(6), 37(g) 16(1), 23(1&2) Requirement The manager must undertake further training in respect of protection and abuse. The manager must ensure that all possible trip hazards are assessed and where appropreat the risk highlighted. Timescale for action 01/03/07 30/01/07 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 Refer to Standard OP10 OP14 Good Practice Recommendations The manager should seek the permission of the service user in writing for the use of an infant monitor in her bedroom. The Service User should be encouraged to participate and sign all documentation personal to her. Andover Close (31) DS0000039293.V322438.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V322438.R01.S.doc Version 5.2 Page 23 - 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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