Inspection on 16/06/06 for Caroline House

This inspection was carried out on 16th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Caroline House 23/07/07

Caroline House 18/10/05

Caroline House 24/06/05

Caroline House 24/02/05

Caroline House 01/07/04

Caroline House 09/02/04

Caroline House 18/09/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Caroline House 114 Consfield Avenue New Malden Surrey KT3 6HE Lead Inspector Emma Dove Unannounced Inspection 16th & 21st June 2006 3:45 Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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 Caroline House DS0000027207.V295689.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 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. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caroline House Address 114 Consfield Avenue New Malden Surrey KT3 6HE 0208 336 2600 0208 336 2600 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) Sons of Divine Providence Miss Wendy Broadhurst Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18/10/05 Brief Description of the Service: Caroline House is a care home for five adults with learning disabilities. It is owned by a housing association and managed by the organisation Sons of Divine Providence, who have three other care homes in the local area. Five people are currently living at the home. The home is situated in a residential area of New Malden close to local shops, leisure facilities with good public transport links. It is in keeping with neighbouring houses and is not easily identifiable as a care home. Accommodation is provided over two floors with one bedroom, staff office, lounge, kitchen/dining room and laundry area on the ground floor. The remaining four single bedrooms, two bathrooms and a staff sleep-in room are available on the first floor. To the front of the home is parking for one car with more parking available in the road. To the rear of the home is a large well maintained garden with garden furniture. The home is staffed twenty-four hours a day. Inspection reports are available at the home and details of the CSCI are included in the Statement of Purpose and Service Users Guide to the home. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of four and a half hours on the 16th June 2006 and two hours on the afternoon of 21st June 2006 by one regulatory inspector. The inspection consisted of examination of records, inspection of communal areas and two bedrooms, talking to residents and the manager. The inspector had the opportunity to speak with four residents and two members of staff. Questionnaires were given to one resident, two relatives, two advocates, two social workers, four health care professionals and one day centre. Six completed questionnaires have been received and comments from these are included in each relevant section of this report. What the service does well: What has improved since the last inspection? What they could do better: Residents files should be updated to reflect changes in staff. Further work is required to develop Person Centred Plans for all residents to ensure their needs are recorded and can be met by staff. Radiator covers must be fitted or radiators should be replaced ‘low surface temperature’ radiators to ensure residents health and safety are maintained. A copy of the electrical supply report must be available at the home. Staff files must contain copies of references and CRB checks to ensure recruitment policies and practices are followed. Staff must receive regular supervision to A structured ‘handover’ should be provided for the new manager to ensure they are aware of residents needs and policies, procedures and practices. Caroline House DS0000027207.V295689.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. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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 Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for new and prospective residents and their relatives to make an informed choice regarding moving into the home. Assessments are completed on admission and developed into care plans. EVIDENCE: The Statement of Purpose and Service Users Guide to the home contain details required to assist prospective residents in choosing whether to move into the home. Changes have not been made to these documents since the last inspection in October 2005. Questionnaires indicated that individuals chose to move into the home and received information they needed to make the choice. Assessments were completed on admission to the home and developed into care plans which are reviewed annually. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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, 7, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Care plans are in place and reviewed with further work required to develop Person Centred Plans (PCP). EVIDENCE: Care plans are in place and have been developed from assessments, which are reviewed twice a year. Progress has been made with developing PCP for residents but require further work to complete. One file noted the previous key worker. The residents weekly timetable should be updated to reflect choices on offer or available to the individual. Case files also contain pictures and photographs from the previous years ‘significant’ events, for example holidays, Birthdays and parties held at the home. This is an excellent record and good talking point for residents and staff. Risk assessments are in place. Questionnaires indicated that relatives and advocates are kept informed and up to date with changes in the residents needs. One questionnaire noted that resident’s specific needs regarding religion and disability are well met. Residents meetings have been held every week until the end of May 2006. Residents are involved in choosing the menu, planning events, outings and holidays and any issues regarding the house and garden are also discussed at Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 10 residents meetings. Questionnaires indicated that the organisation should give consideration to residents being involved in the recruitment process. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents social needs are met through centres, groups and clubs they attend during the week. EVIDENCE: Four residents attend day centres during the week depending on their wishes and needs. One resident has a programme, which has been developed by staff at the home, which includes attending a number of activities at the home and in the local community. The manager reported that they have been planning an outing for two residents every month in addition to usual clubs and groups attended. Residents attend churches of their choice in the local community. Questionnaires indicated that residents have activities such a puzzles, books, drawing as well as the television, music and spending time in the garden to occupy their time. One resident said that they are looking forward to their holiday. Plans were well under way with new clothes purchased and lots of excited conversation about what they were going to do. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 12 Questionnaires identified that residents are supported to maintain contact with relatives and friends. Visitors are welcome and invited to attend a number of celebrations throughout the year. Residents were observed being offered choices in meals and activity. Residents are fully involved in meal planning and preparation and special dietary needs are accommodated in the menu. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive appropriate support and personal health care. EVIDENCE: Residents are all registered with a GP, staff support individuals to attend appointments. Questionnaires from health professionals indicated that staff deal appropriately with residents when attending appointments. Medication policies and procedures ensure residents health and welfare are maintained, however some recording practices are not so robust. Two recent incidents have occurred when staff have not recorded when an individuals medication should commence. The manager reported that these issues had been dealt with and recording practices have been reviewed to prevent similar occurrences. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate complaints and protection of vulnerable adults policies and procedures are in place, however the recording practices for complaints do not clearly indicate the outcome. EVIDENCE: The complaints procedure is included in the Statement of Purpose and Service Users Guide to the home. Questionnaires indicated that residents, relatives and advocates were aware of how to complain. Records identified that a resident made a complaint about another service, not the home, in October 2005. It was not clear from the records whether the complaint had been addressed. The CSCI has not received any complaints regarding the home. Protection of vulnerable adults policies are in place and the manager is aware of the responsibilities regarding protection of residents. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 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, 25, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely environment is maintained to a good standard with the exception of the kitchen and one bathroom. EVIDENCE: The house has been extended and developed over the years to meet the needs of current residents. One bedroom is on the ground floor with an ensuite bathroom, other bedrooms and bathrooms are on the first floor which is accessed via a steep and narrow staircase. As residents needs change the home may become less accessible to individuals. Bedrooms are single and have been personalised with photographs and pictures to individual taste. Residents have access to a lounge with doors to the garden and a kitchen/dining room. All areas of the home have been personalised with pictures and photographs of residents and staff. Two bathrooms with toilet are available on the first floor. One bathroom must be redeveloped to meet resident’s needs. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 16 Radiators in the home do not have covers and are not low surface temperature style. Risk assessments must be in place to ensure residents health and safety is maintained and radiator covers must be fitted or radiators replaced with low surface temperature ones. Requirements have been made regarding the kitchen being repaired or replaced at the last two inspections. Progress has not been made with this issue. All areas of the home were clean. Residents confirmed that they keep their bedrooms clean with staff support. Staff maintain communal areas of the home to a good standard of cleanliness. The laundry is next to the kitchen/dining room with clear guidance for staff regarding infection control. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 17 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, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are appropriate to meet residents needs and staff have access to training and development sessions. EVIDENCE: The published staffing rota identified two members of staff on duty during the day with one member of staff asleep but on call at night. All staff are female which is appropriate to meet residents personal care needs. The staff group do not reflect the ethnicity of residents, however no issues were raised regarding this. Residents reported that they like staff. Questionnaires indicated that less reliance on agency staff would be beneficial to the staff team and for the residents. The organisation has training and development sessions for staff. Staff have completed training in infection control, fire safety, medication, Person Centred Planning, sensory awareness, staff supervision, first aid, moving and handling with one member of staff trained to NVQ Level 2 and 3. Appropriate recruitment and selection policies and procedures are in place, however not all records required by Regulations were in place for one member of staff. One staff file contained a copy of the individuals birth certificate, application form, confirmation that a Criminal Records Bureau check had been Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 18 completed and two written references. One staff file did not contain copies of references or a copy of the individuals birth certificate. The manager reported that she had seen the references while at the organisation’s head office. Supervision dates indicated that one member of staff has received supervision every other month since the last inspection, however two members of staff had only received supervision twice and another member of staff had had three sessions. One member of staff had not had any supervision. The manager reported that this was an agency member of staff. Records indicated that the manager had not received regular supervision during the last year. Appraisals are carried out annually for staff. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 19 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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in the day to day running of the home and benefit from the way it is run. EVIDENCE: The manager has been at the home for a number of years and is aware of residents needs and how to meet them. The manager is due to leave the home in August 2006, adverts have been placed to recruit a new manager although at the time of the visit no applications had been received. Questionnaires identified concerns about a timely appointment, the suitability of prospective candidates and what kind of ‘handover’ will be in place to ensure the new manager receives a thorough induction to the home. Regular reviews are held at which residents and their representatives are asked for comments regarding the services provided. A representative from the organisation visits the home every month and completes an audit of records, finances and speaks with residents and staff about their experiences at the home. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 20 Health and safety policies, procedures and practices are good with records maintained and up to date with the exception of the electrical supply certificate which must be available at the home. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 21 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 15 Requirement The registered person must ensure that Person Centred Plans are complete for all residents. Timescale for action 21/08/06 2. YA22 22 (3) The registered person must 21/08/06 ensure that complaints records clearly indicate actions taken and the outcome. The registered person must ensure that the kitchen cabinets are repaired or replaced. (timescale of 12/05/05 & 30/11/05 not met) The registered person must ensure that the ‘green’ bathroom is redeveloped to meet residents needs. The registered person must ensure that radiator covers are provided or radiators are replaced with low surface temperature type and for risk assessments to be completed to ensure residents safety is protected. The registered person must DS0000027207.V295689.R01.S.doc 3. YA28 16 (2) m &n 25/09/06 4. YA27 23 (1) m 21/08/06 5. YA24 12 (1) 21/08/06 6. YA34 19 (1) 21/08/06 Version 5.2 Page 23 Caroline House Sch 2 7. YA36 18 (2) ensure that staff files contain copies of references and proof of identity. The registered person must ensure that all staff receive regular supervision. The registered person must ensure that a copy of the electrical supply test is available at the home. 21/08/06 8. YA42 12 (1) a 21/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations The registered person should ensure that information in resident’s files is updated to reflect staff at the home. Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Caroline House DS0000027207.V295689.R01.S.doc Version 5.2 Page 25 - 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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