Inspection on 24/10/05 for Andover Close (31)

This inspection was carried out on 24th October 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

Andover Close (31) 17/12/08

Andover Close (31) 18/12/06

Andover Close (31) 12/01/06

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 24th October 2005 11:00 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.V260706.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V260706.R01.S.doc Version 5.0 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.V260706.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th December 2004 Brief Description of the Service: 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 ensuite 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.V260706.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first 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 manager was present. The service had a homely and welcoming atmosphere. The resident was happy to talk about life in the home. During the inspection process, documents inspected, included a resident file, care plan, and the homes policies and procedures. 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: The home has produced a comprehensive, 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. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 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.V260706.R01.S.doc Version 5.0 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): 1,2,3,6 The home has developed a Statement of Purpose, and service user, which would provide enable a resident with the information required. Contracts were in place and arrangements were in place to ensure a full needs assessment takes place before any new admission. The home does not provide for intermediate care. EVIDENCE: The home has developed a service user guide and complaints policy and procedure. Both of these documents are easy to read and understand, however they did not reflect the current details of the CSCI. The resident had a comprehensive assessment of needs, which was carried out by the manager before the resident was admitted to the home. All aspects of daily living needs were assessed, indicating that the manager would be fully aware of the residents care needs. The resident’s file contained a written and signed contract, and a statement of terms and conditions. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 9 The home does not provide for intermediate care. A requirement was made in these areas. Please refer to page 23 of this report. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 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. Medication procedures were in place. 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. There was evidence to suggest that the care plan was reviewed on a monthly basis. There was documentation regarding changes in healthcare needs and evidence of visits to GP’s, and other health professionals. On the day the manager stated, that the resident was not prescribed any medication. There were records with regard to the activities and care being given, documented on a daily basis. These records were very concise, and on the whole task focused, however gave an indication of all day-to-day activities. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 11 A recommendation has been made in these areas. Please refer to page 23 of this report. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14. The manager enables the resident to maintain a fulfilling lifestyle both in the home and community. The manager promotes contact with family and friends. EVIDENCE: The resident’s care plan, included information with regard to social, cultural, religious and recreational interests and needs. On the day of inspection, no restrictive practices were observed. The resident was still in her night attire and was enjoying a late breakfast. The manager was observed offering the resident four different choices of clothes for the day, and discussing plans for the day’s activities. A trip to the library was decided upon. On the day, the manager was familiar yet respectful, to the resident. It was evident from the positive interactions and relationships, which have been formed, that she had a good understanding of the resident’s support needs. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 13 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): 16,18. 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. The resident explained that she knew how to make a complaint, if she had to. 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 that she should be using the updated version ( February 2005). Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 14 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): 19,20,21,22,23,24,25,26. 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: The resident’s bedroom was personalised. It was clean bright, tidy and free from offensive odours. The quality of the furniture and decoration, though quite modern in design was good. There were photographs of family members and other personal items. The resident stated that “ I love my room, it is nice and clean”. The main sitting room was warm and cosy, although somewhat cluttered, mostly with children’s toys. This was discussed with the manger, who gave a satisfactory explanation as to why. The standard of decoration in the hallway and communal room was satisfactory. The manager stated that they were in the process of re decorating these areas. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 15 The home is in the process of converting a downstairs storage area into a toilet for the resident’s personal use. The ensuite shower area was clean and free from odours. Water temperatures were checked, and were found to be satisfactory. On the day records were not available, however the manager stated that, water temperatures were regularly checked and recorded. The registered person(s) are in the process of adding an extension to the home in order to increase the usable space. This is almost completed and will provide a very pleasant place for the resident to spend time. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 16 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 as there are no care staff employed at this home. EVIDENCE: Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 17 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): 31,33,37,38 The manager is experienced and qualified to run the home. The home has clear Policies and Procedures and the standard of record keeping is good. Health and safety checks are routinely carried out at the home and records kept. EVIDENCE: On the day of inspection the manager demonstrated an open approach and management style. From observation of her interactions with the resident it was clear that there was an atmosphere of openness and respect and that a close relationship had developed between the resident, the manager and other members of the family. There are clear and policies and procedures in the home. The resident can access them when they wish. The resident has control over her own financial affairs. The manager assists Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 18 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. Throughout this inspection the home records were accessed. The recordkeeping was satisfactory. Records were stored appropriately, securely and confidentially. Health and safety checks are routinely carried out at the home. All equipment in use on the day of inspection was properly maintained, the manager stated that routine checks are carried out, but was unable to evidence any records as they were locked away. Fire alarm checks had recently been carried out. Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 Page 19 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 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 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 3 X 3 X X X 3 3 Andover Close (31) DS0000039293.V260706.R01.S.doc Version 5.0 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 OP 1A Regulation 5 (1)(e(f) Sch 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. Timescale for action 24/12/05 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 OP 37 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.V260706.R01.S.doc Version 5.0 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.V260706.R01.S.doc Version 5.0 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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