Inspection on 23/11/05 for Banstead Road South (21)

This inspection was carried out on 23rd November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Banstead Road South (21) 27/11/07

Banstead Road South (21) 19/03/07

Banstead Road South (21) 13/07/05

Banstead Road South (21) 11/02/05

Banstead Road South (21) 06/09/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Banstead Road South (21) 21 Banstead Road South Sutton Surrey SM2 5LF Lead Inspector Deborah Yapicioz Unannounced Inspection 23rd November 2005 13:50 Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 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 Banstead Road South (21) DS0000007211.V266525.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 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. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Banstead Road South (21) Address 21 Banstead Road South Sutton Surrey SM2 5LF 020 8770 0106 020 8770 0106 max.edward@surreyoaklands.nhs.uk 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) Surrey Oaklands NHS Trust Mr Max Anton Edward Care Home 7 Category(ies) of Learning disability (0), Sensory impairment (0) registration, with number of places Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow three specified service users over the age of 65 years to be accommodated A variation has been granted to allow three specified service users over the age of 65 years to be accommodated until such time that the home is no longer able to meet their assessed needs. A variation has been granted to allow one specified service user with a physical disability to be accommodated A variation has been granted to allow one specified service user with a physical disability to be accommodated until such time that the home is no longer able to meet their assessed needs. 13th July 2005 2. Date of last inspection Brief Description of the Service: 21Banstead Road South is registered with the Commission for Social Care Inspection to provide residential care for up to seven adults with learning disabilities and hearing impairments. There are currently seven service users living permanently at the home. The home is owned, managed and staffed by The Surrey Borders Partnership National Health Service Trust formally the Surrey Oaklands Trust, a specialist health provider for people with learning disabilities. The home is a large detached house built over two floors comprising of seven single occupancy rooms, a dining room, a lounge, a kitchen laundry and quite room. 21 Banstead Road South is situated on a residential road in Sutton. It is close to local shops and transport links. The home also has a large garden equipped with garden furniture. The home also has its own minibus which is used to access other community facilities and day care. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place on the afternoon of 23rd November 2005. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. A previous inspection took place on 13th July when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Many of the staff team were involved in a staff training session, so the inspection was spent meeting with support worker Maria Hay, looking at records, and talking to service users and a tour of the premises. The inspector would like to thank the service users and the staff team for their help in facilitating the inspection. Overall the home continues to provide a good standard of care to the people living there. What the service does well: What has improved since the last inspection? Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 6 At the previous announced inspection it was identified that one of the service users who needs had changed was in need of a reassessment. Since the last inspection an assessment has been completed and it was decided that his needs would be better met in a different setting. An appropriate placement has been identified and he will be moving in the near future. The home has also appointed a permanent deputy manager 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. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. EVIDENCE: The home has a statement of purpose and a Service users guide in place. The service users at 21 Banstead Road have learning disabilities and hearing impairments so the service user guide has been put into Widget symbol format. The home has a procedure for introducing service users to a new residential placement, which includes the homes, own assessment process and introductory visits. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. The Royal Association for Deaf People was involved in the assessment process for the latest service user who moved to the home. Each of the service users has a personal contract, specifying the terms and conditions of their occupancy that included periods of notice, fees charged, and the cost of ‘extras’ not covered by the basic cost of the placement. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 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, The service users have comprehensive individual care plans with detailed information on their needs and personal goals. Individual care plans include consultation with service users and are regularly updated by the key-worker to reflect current needs and ensure service users wishes are represented. EVIDENCE: Each of the service users has an individual tailored care plan. Service user individual care plans are based on Person Centred Planning principles and are very detailed and comprehensive. One of the service users has recently has his care needs reassessed in lighting of his changing needs. The home is in the process of seeking a more appropriate placement for him. The care plans are reviewed regularly and copies of the service users most recent reviews where on the service users files. The Royal Association for Deaf People provide support to the service users at their review meetings. This entails meeting with the service user before the review to make sure they are happy and supporting them at the actual meeting. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,17 The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. Dietary needs are catered for with meals that are nutritionally well balanced, nicely presented, and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options EVIDENCE: It is part of the role of the staff team to encourage service users at the home to maintain and develop independent living skills. The service users have a weekly activity timetable and details of the service users weekly commitments are also recorded on service users files. There is a strong emphasis on service users using the community facilities. The home has started to plan the activities for the Christmas period including seeing the lights in London, meals out and a visit to the circus. Many of the service users have lived at 21 Banstead Road South since it opened and are getting older; the home has adapted their routines to accommodate the “slower” lifestyle of the service users. The service users spoken to during the inspection said that they were very happy at the home and were looking forward to Christmas. The menus at the home are based on the likes and dislikes of the service users. The menus at the home are in a picture/symbol format and service Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 11 users assist with meal preparations. The staff team at the home translate the recipes from the cookery evening class into symbol format for the service users. The home has been awarded a healthy eating award from the London Borough of Sutton. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical and emotional health needs are detailed in personal plans to offer consist care in this area. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. The level of personal support a service user needs would be detailed at their review and recorded in their personal file. Personal care is provided in private, and timings of this are also flexible. The home provides consistency and continuity through designated key workers All service users are registered with a local General Practitioner. The staff team at the home monitor the health of each of the service users and would ensure they receive any treatment needed. Incident forms are completed following any accidents. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 13 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 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The complaints procedure is also in a symbol format. The home has a copy of the local authority Adult Protection Policy on site. The Surrey Borders Partnership Trust provides mandatory Vulnerable Adults training for staff. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 14 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 This home provides a comfortable, clean and safe environment for service users to live in. The general décor of the home is good with the exception of the lounge and hall carpets, which need attention. EVIDENCE: The home is situated on a suburban street in Sutton reasonably close to local shops and facilities. The home was comfortable, bright, well ventilated and free from offensive odours on the day of the inspection. The home’s premises are in keeping with the local community and appear suitable for their purpose. The communal facilities include a lounge, dining room, kitchen and quiet room. The overall condition and décor of the home was good. At the previous inspection there were two areas that were identified as in need of replacement These were, the carpet in the lounge that has an iron burn mark and the carpet in the hallway outside the kitchen which is stained and worn and should be replaced. The management team have obtained quotes for this and are confident the replacements will be in place shortly. The bedrooms at the home are furnished and decorated to reflect the individual tastes of the service users. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 15 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): 32,35 The staff team at the home have a range of skills and abilities including a knowledge of sign language, which enables them to communicate with, and meet the needs of, the service users living at the home. The staff team have now all had Criminal Records Check, as a safeguard to offer protection to the homes service users. EVIDENCE: There are at least two members of staff on duty in the home at any one time. During the day when there are a lot of activities the manager arranges for three people to be on duty. At night there is one waking and one sleep in member of staff. The home has now got a permanent deputy manager. The home has devised a pictorial rote of staff, to assist service users in identifying the staff on duty. Surrey Oakland’s trust has an equal opportunities policy, which includes a recruitment, and selection procedure. Criminal Records Checks are completed as part of the recruitment process. Criminal Records Checks have been obtained for all permanent staff currently working at the home. The staff team at the home all use signing as a means of communication any new staff recruited to the home must have signing skills or be prepared to learn. The deputy manager and another member of the care team are attending a signing course. The home offers training opportunities to staff at all levels within the home. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 16 New members of staff complete an induction programme covering various subjects including health and safety issues. At the time of the unannounced inspection the staff team were participating in a refresher course for Basic food hygiene. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 37,42 The management style is open and the home appears to be well run. There are clear lines of accountability, which is aimed at ensuring the interests of the service users, are safeguarded and their safety and welfare are protected. EVIDENCE: The registered manager of 21 Banstead Road South is Mr. Max Edwards. Mr Edwards has been a qualified Registered Nurse for People with Mental Handicap for over twenty-five years and has extensive experience in residential care. Mr Edwards has achieved a National Vocational Qualification, level four and is a trainer on the “Positive Futures” course. The management approach at the home appears to be a very ‘open’ and inclusive one. Both staff and service users are encouraged to participate in the day-to-day operation of the home and to give their opinion about the way the service is delivered. The home arranges for the Royal Association for Deaf People to facilitate the service users meetings at the home. They also assist with service users reviews and any medical appointments. The home has a health and safety policy and an Infection control manual. Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 18 The staff team take responsibility for different areas within the home. Audits are in place covering different aspects of the home including, financial audits, health and safety and maintenance. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards and knives were seen in the kitchen and “health and safety law” posters are on display around the home. There are locked “Control of Substances Hazardous to Health” cupboards. The staff team have access to training around health and safety issues Banstead Road South (21) DS0000007211.V266525.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Banstead Road South (21) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000007211.V266525.R01.S.doc Version 5.0 Page 20 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. 2. Standard YA24YA24 YA24 Regulation 23(2)(d) 23(2)(d) Requirement The home manager must replace the lounge carpet with the iron mark The home manager must replace the stained and worn carpet on the ground floor hallway outside the kitchen The home manager must ensure all medication records are correctly filled in at all times Timescale for action 31/01/06 31/01/06 3. YA20 17(1)(a)3 3.(I) 23/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Banstead Road South (21) DS0000007211.V266525.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Banstead Road South (21) DS0000007211.V266525.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. 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