CARE HOME ADULTS 18-65
Brighton Road (47-49) 47-49 Brighton Road Purley Surrey CR8 2LR Lead Inspector
Mohammad Peerbux Unannounced Inspection 14th November 2005 9:20 Brighton Road (47-49) DS0000028161.V265486.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 Brighton Road (47-49) DS0000028161.V265486.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. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Brighton Road (47-49) Address 47-49 Brighton Road Purley Surrey CR8 2LR 020 8660 4078 NO FAX thfcare@brightonroad.fsnet.co.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) THF Care Estates Limited Ms Lorraine Bright Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: 47/49 Brighton Road is owned, managed and staffed by THF Care Estates Limited. The property is registered with the Commission for Social Care Inspection (CSCI) to provide residential care for up to fifteen adults with moderate learning disabilities. The home provides residential care for younger adults aged between 18 and 65 the vast majority of whom have lived together for many years, with the result that they seem very comfortable in one anothers company. The property is situated on a busy residential road close to the centre of Purley and is well placed for local shops and public transport links. There is ample space in the front garden for parking. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/06. It was an unannounced inspection and took place over two and half hours. Some times were spent looking at the policies and procedures, talking to the manager and staff. A tour of the building was also carried out. Requirements and recommendations from the previous inspection were also discussed with the manager. They are all thanked for their time and assistance. An immediate requirement was issued during this inspection as the hot water temperature in two bathrooms was above the recommended level of 43 degrees centigrade. What the service does well: What has improved since the last inspection?
The Service User’s Guide now makes reference on how to access a copy of the latest inspection report in line with requirement made at the last inspection. All service users have contracts in place and these are signed by all parties concerned and there is an accurate records service user’s monies. The complaints procedure has been reviewed to include the stages and timescales for response and to reflect the change in regulatory organisation to the Commission For Social Care Inspection. The home has recently been awarded ‘ Investor in People’. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 6 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. Brighton Road (47-49) DS0000028161.V265486.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 Brighton Road (47-49) DS0000028161.V265486.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 and 5 In general the Statement of Purpose and Service User’s Guide provide prospective service users with details of the services the home offers. This enables them to make an informed decision about admission to the home. EVIDENCE: The manager has reviewed the Statement of Purpose however some information are still missing. The registered Person must ensure that all information are included in Statement of Purpose as per schedule1 of the Care Standard Act 2000 .The Service User’s Guide now makes reference on how to access a copy of the latest inspection report in line with requirement made at the last inspection. Service users or their recognised representatives are provided with a costed contract/statement of terms and conditions of occupancy that are agreed between each prospective service user and/or representative and the home. It was previously required that the registered person must ensure that all service users contracts are signed by all parties concerned. Three contracts were sampled at random and they were all signed accordingly. Brighton Road (47-49) DS0000028161.V265486.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): 7 and 10 Service users are involved in decision-making about their lives so that they live as normal a life as possible. The home has a confidentiality policy in place, which ensure information is handled in the best interests of the service users. EVIDENCE: The rights of service users to make decisions about their own lives is central to the ethos of the home, support and guidance is given in all areas to ensure that service users are making decisions which are in their best interests. Where possible service users are actively encouraged to manage their own financial affairs and one service user in particular retains their own Bank Book, which they use to good effect to make withdrawals and deposit money as they wish. It was previously required that the registered person must ensure that accurate records are kept as far as service users’ monies are concerned. Service user’s financial records were in the main clear, accurate and appropriately maintained. The home has a confidentiality policy in respect of personal information held in relation to service users. General service user’s documentations (i.e. service user plan, medical appointments and reviews) are kept locked in the office.
Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 10 Staff respect information given by service users in confidence, and handle information about service users, in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13 and 14 Service users are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. EVIDENCE: The inspection findings indicated staff work very closely with the service users to develop independent living skills at the home. It was observed staff assisting users with making decisions about tasks, activities inside and out of the home. Evidence recorded in individual care plans also indicated staff offer support, advice and other input that help to enhance and develop independent living skills. Service users are able to access a wide range of community activities and resources including swimming, mencap, bingo, horse riding, social evening, local pubs, discos and restaurant. Activity plans are individualised. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 12 The service users are clearly all able to express their social / leisure needs and interests. Staff support service users in pursuing these activities if and when necessary / requested. Service users take part in a range of local leisure activities. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 Generally service users’ medication is well managed to ensure maximised good health. However the wishes of the service users upon illness and death still need to be sought. EVIDENCE: The home has a policy on the administration of medication. Medications are stored in a locked cupboard. Records examined showed that all medicines administered are recorded on Medicine Administration Record Sheets, which were up to date at the time of the inspection. The home does have any records of the service user’s last wishes. The manager must ensure that the service users and/or their relatives have been consulted about their last wishes and these must be documented in their personal files. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 14 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 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint. It was previously required the complaints procedure must be reviewed to include the stages and timescales for response and to reflect the change in regulatory organisation to the Commission For Social Care Inspection. The complaints procedure has been amended. Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 15 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 and 25 Although the environment and furniture generally met the service users’ needs, parts of the environment does not fully promote the service users well being. EVIDENCE: Most of the requirements made at the last inspection regarding the environment of the home have not been met and therefore will be repeated. It was previously required that the external paintwork of the house the mid and top landing be decorated and repaired, the side gate and the broken glass in the basement windows be replaced. The manager must discuss these issues with the proprietors, as this requirement cannot be carried forward indefinitely. Failure to comply with the aforementioned requirement represents serious breaches of the Regulations and urgent action must be taken by the registered persons to address this to avoid the Commission taking further action to enforce compliance. The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedroom are personalised to reflect their individual needs, and personalities.
Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 16 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): 34 One concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of service users being ensured. EVIDENCE: As part of the inspection process staff records were sampled for references, criminal record checks, application forms and copies of identification. It was noted that two staff files did not have any identifications and another did not have a photograph and had only one reference. The registered manager must ensure that staff files contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001. This was a requirement from the last inspection and therefore would be repeated. Brighton Road (47-49) DS0000028161.V265486.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): 39 and 42 The home is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: Service users and their families are consulted about the conduct of the home and their views are regularly sought by means of the telephone, invitations to reviews, and for some, regular visits to the home, where relatives are able to meet and talk directly with care staff and the manager. The manager stated that the home has a development plan in place. It was previously required that the registered person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. During this inspection it was noted that one of the fire doors was wedged open and therefore this requirement will be repeated. The registered manager is reminded that she must ensure so far as Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 18 is reasonably practicable the health, safety and welfare of service users and staff. During the inspection it was also noted that the hot water temperature in the two bathrooms were above the recommended level of 43 degrees. An immediate requirement was issued to address this issue. Brighton Road (47-49) DS0000028161.V265486.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 2 X X X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Brighton Road (47-49) Score X X 3 2 Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000028161.V265486.R01.S.doc Version 5.0 Page 20 YES 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 YA1 Regulation 4 Requirement The Registered Person must ensure that all information is included in Statement of Purpose as per schedule1 of the Care Standard Act 2000. (Previous timescale of 30/09/05 not met). The manager must ensure that the service users and/or their relatives have been consulted about their last wishes and these must be documented in their personal files. The Registered Person must ensure the outside of the house is repainted and maintained on a regular basis. (Timescale of 31/08/05 not met). The Registered Person must ensure that the mid and top landings are decorated. (Timescale of 31/09/05 not met). Timescale for action 31/01/06 2. YA21 12 31/01/06 3. YA24 23(2)(b) 31/03/06 4. YA24 23(2)(b) 31/01/06 5. YA24 23(2)(b) The Registered Person must 31/01/06 ensure that the side gate is replaced. (Timescale of 31/09/05 not met).
DS0000028161.V265486.R01.S.doc Version 5.0 Page 21 Brighton Road (47-49) 6. YA24 23(2)(b) The Registered Person must 31/01/06 ensure that the broken glasses in the basement windows are replaced. (Timescale of 31/09/05 not met). The Registered Person must ensure that the lawn is cut and the garden is properly maintained. The Registered Person must ensure copies of Birth Certificates, Passports (if any); a recent photograph; enhanced CRB check and any other documents laid down in this standard or schedules are available for inspection in the home at all times in respect of all staff employed. (Timescale of 31/09/05 not met). The Registered Person must ensure that fire doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. The Registered Provider must ensure that the hot water temperature is always within recommended level. 31/01/06 7. YA24 23(2)(o) 8. YA34 17(2) 31/01/06 9. YA42 23(4)(c) 14/11/05 10. YA42 13 15/11/05 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 Brighton Road (47-49) DS0000028161.V265486.R01.S.doc Version 5.0 Page 22 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
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