Inspection on 18/10/05 for Caroline House

This inspection was carried out on 18th 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 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 2 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 16/06/06

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 18th October 2005 09:30 Caroline House DS0000027207.V261957.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 Caroline House DS0000027207.V261957.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. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 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.V261957.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 2005 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 the 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. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 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 two hours one morning and one hour one afternoon by one regulatory inspector. The inspection consisted of examination of records, inspection of communal areas talking with residents and staff. The inspector had the opportunity to speak with four residents and three members of staff. What the service does well: What has improved since the last inspection? What they could do better: Further work is required to complete PCP’s for all residents. To ensure residents and staffs health and safety, the worn lino on the stairs should be repaired or replaced. Attention should be paid to the cabinets in the kitchen, which are worn. Caroline House DS0000027207.V261957.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. Caroline House DS0000027207.V261957.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 Caroline House DS0000027207.V261957.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): 2 Resident’s needs are adequately assessed prior to admission and reviewed and updated periodically. EVIDENCE: Current residents have been at the home for over six years. On admission to the home, needs assessments are completed which are updated and developed into care plans. Caroline House DS0000027207.V261957.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&9 Residents are encouraged and assisted in making decisions regarding their lives. Residents participate in the day-to-day running of the home. Residents are protected from harm by appropriate risk assessments being in place. EVIDENCE: Residents are involved in developing their care plans and attend reviews of the care that they receive. Two residents confirmed that they attended reviews recently and make decisions regarding their future. Residents are involved in daily decisions regarding meals, activities and holidays. One resident said ‘I chose my holiday’. One resident confirmed that they are involved in choosing meals, holidays and activities. Risk assessments are in place for individual residents, ensuring staff have up to date information to meet individuals safety needs. Risk assessments have been reviewed following incidents and appropriate actions taken to prevent similar occurrences. Caroline House DS0000027207.V261957.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): 15, 16 & 17 Residents are supported and encouraged to maintain contact with relatives and friends. Residents rights are protected. Residents are involved in all aspects of meal preparation at the home. EVIDENCE: Residents are assisted and supported by staff in maintaining contact with family and friends, with sending celebration cards and invites to events and parties at the home. Staff reported that residents relatives and friends were invited to a recent naming ceremony at the home. Two residents confirmed that people they wished to attend the naming ceremony were invited. Residents meetings and reviews ensure residents are involved in decisionmaking and the day-to-day running of the home. The home provides a varied menu which residents are involved in choosing. Residents are encouraged to be involved in all areas of meal preparation from shopping to cooking and clearing away. One resident said ‘my job is to lay the table’ and another resident said ‘I shop for food’. Residents comments regarding the food they receive were positive, including ‘I like the food’ and ‘I’m looking forward to dinner tonight’. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 11 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): 19 & 20 Residents health needs are well met at the home. Residents are protected by policies, procedures and practices regarding medication storage, administration and recording in place at the home. EVIDENCE: Residents are registered with a GP and visit the chiropodist, optician and dentist as required. Records are maintained of visits to health professionals. Policies, procedures and practices regarding medication ensure residents health and welfare are maintained. Medication is securely stored at the home. Staff administer medication to residents from blister packs made up by the pharmacist. Medication Administration Records were up to date and signed. Records are maintained of medication received at the home and returned to the pharmacist. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 12 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): 23 Appropriate policies and procedures are in place to protect residents from abuse and harm. EVIDENCE: The organisation has a policy for the protection of vulnerable adults and copies of the placing authorities policies are available at the home, ensuring residents protection. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 13 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, 27 & 30 The home is maintained to a good standard of cleanliness and hygiene. EVIDENCE: The lino on the stairs is in need of repair or replacing to ensure residents and staffs health and safety is maintained. Residents have access to a toilet on the ground floor and two bathrooms with toilets on the first floor. One resident has an ensuite bathroom. All areas of the home were clean. The laundry area is by the kitchen/dining room but is not accessed from bedrooms. Policies are in place for the control of infection. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 14 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 Residents needs are met by long-standing and new staff who are appropriately trained. EVIDENCE: The published rota identified two members of staff on duty during the day with one member of staff asleep but on call at the home at night. These staffing levels were observed to be sufficient to meet residents needs. Progress has been made with the recruitment of permanent staff at the home with one new member of staff in post and one member of staff awaiting a start date when the recruitment checks are complete. The organisation has a training and development programme which is available to all staff. One newly recruited member of staff confirmed that they had completed an induction to the organisation and the home and is in the process of completing NVQ to Level 2. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 15 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 A senior member of staff has been covering for the manager for the last three months, she demonstrated a clear understanding of the service and areas which need developing. Residents are involved in the day-to-day running of the home and their views and needs are taken into account. EVIDENCE: The manager has been away from the home for three months and a senior member of staff has been covering the management responsibilities at the home. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 16 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 X 3 X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Caroline House Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000027207.V261957.R01.S.doc Version 5.0 Page 17 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 2 Standard YA24 YA28 Regulation 23 (2) b 16 (2) m &n Requirement The registered person must ensure that the lino on the stairs is repaired or replaced. The registered person must ensure that the kitchen cabinets are repaired or replaced. (timescale of 12/05/05 not met) Timescale for action 30/11/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations The registered person should ensure that Person Centred Plans are developed for all residents. Caroline House DS0000027207.V261957.R01.S.doc Version 5.0 Page 18 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.V261957.R01.S.doc Version 5.0 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!