Inspection on 23/07/07 for Caroline House

This inspection was carried out on 23rd July 2007.

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 16/06/06

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 23rd July 2007 1:30 Caroline House DS0000027207.V344865.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.V344865.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.V344865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caroline House Address 114 Consfield Avenue New Malden Surrey KT3 6HE 020 8336 2600 F/P 020 8336 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 Margaret Mudavanhu Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2007 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 there. Caroline House 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 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. Caroline House DS0000027207.V344865.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 four hours on the 23rd July 2007 by one regulation inspector. The inspection included examination of records, looking around communal areas and some bedrooms, speaking with people who use the service, staff and the registered manager. Questionnaires were sent to: two relatives or friends; two placing social workers; one health professional and two other professionals involved with the home. Three questionnaires have been received, comments from these are included in the relevant sections of this report. A completed Annual Quality Assurance Assessment (AQAA) was received in good time for information to be included in this report. What the service does well: What has improved 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. The summary of this inspection report can be made available in other formats on request. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 6 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.V344865.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service understands the importance of having sufficient information when choosing a care home and has developed a Statement of Purpose and Service Users Guide. Assessments are completed prior to admission and kept under review. EVIDENCE: The Statement of Purpose and Service Users Guide contain good information about the service, the organisation, the staff team and policies including how to make a complaint. Two questionnaires noted that people ‘always’ and ‘usually’ get enough information to make decisions about moving in. Assessments are completed before admission and are kept under review and updated when necessary. One questionnaire noted that assessments are ‘always’ completed to ensure accurate information is gathered. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in planning the care that affects their lifestyle and quality of life. Staff understand the importance of people using the service being supported to take control of their lives. Individuals are encouraged to make their own decisions. EVIDENCE: Case files contain general information about the individual, a copy of their weekly timetable and assessments. Person Centred Plans have been developed with the individuals and include photographs. These documents are ongoing and updated as goals are achieved. A key work system is in place and people who use the service have the opportunity to meet their key worker on a regular basis. This enables people who use the service to have a say in the care they receive. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 9 Reviews are held every six months which provides people with the opportunity to plan for their future. Two questionnaires noted that the service ‘always’ meets peoples needs; that the home ‘always’ gives the care and support expected and agreed; that the service ‘always’ and ‘usually’ meets the different needs of people and that the service ‘usually’ supports people to live the life they choose. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 16 and 17 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling people to develop and maintain their social, emotional and independent living skills. Individuals are supported to identify goals and work to achieve them. People who use the service have the opportunity to develop and maintain important personal and family relationships. EVIDENCE: Four people who use the service attend various day centres and classes four or five days a week depending on their needs and wishes. One person has retired from day centres but has a daily programme of activities in the home and local community to met their needs. The manager reported that this daily programme could be improved to include more community activities and that there are plans for this to be developed. People who use the service confirmed that they have enough to do during the day and at weekends. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 11 Service users have access to a music session and aromatherapy and can attend social clubs and churches of their chosen denomination every week. The organisation has a number of other services in neighbouring areas and has regular parties and activities which people who use the service are welcome to attend. Birthdays and other important anniversarys are celebrated as people who use the service choose. One person reported that they enjoy celebrating their Birthday and another person said that they like Birthday parties and cake. People have the opportunity to go on holiday every year in small groups to a place of their choice. In addition the organisation has regular pilgrimage trips which service users can attend. Service users are supported to maintain contact with relatives and friends. Key workers support people to purchase cards and presents and send them to relatives and friends. Staff have also taken people to visit family members. One questionnaire confirmed that the home always keeps in touch and updates relatives with in People who use the service are involved in choosing the meals provided, shopping, cooking and clearing away after meals. People’s comments about the food included ‘I like the food’ and ‘I enjoy the meals’. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Individual’s personal health care needs are clearly recorded in case files. Staff respect privacy and dignity and are sensitive to peoples changing needs. Medication is well managed, records are fully completed and signed. EVIDENCE: People’s health care needs are noted in case files and Person Centred Plans. Service users are registered with a GP and are supported by staff to attend appointments. People who use the service have an annual health check and have their health care needs met. One questionnaire noted that people’s health care needs are always monitored and attended to, that medication is always administered correctly and that dignity and privacy is always respected. Staff are aware of privacy and dignity and were seen to offer people support in a discreet manner. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 13 Appropriate medication policies and procedures are in place. Staff complete training in the administration of medication. Medication Administration Record Sheets were up to date and signed by staff. Caroline House DS0000027207.V344865.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clearly written and accessible to people who use the service, their relatives and representatives. A policy is in place for the protection of vulnerable adults and staff complete training in the area of protection. EVIDENCE: The complaints procedure is included in the Statement of Purpose. Records are kept of complaints received. People who use the service said that they would speak to the manager, staff or friends if they had any problems or worries. No complaints have been received at the home or by the CSCI since the last inspection. The manager reported that the service is looking at ways to make the complaints procedure more accessible to people who use the service. One questionnaire noted that the person is aware of how to make a complaint and that complaints are ‘usually’ responded to appropriately. One questionnaire indicated that the person was not aware of how to make a complaint although they stated that they had ‘never had any concerns’. One questionnaire noted that the service ‘always’ responds appropriately to concerns. Caroline House DS0000027207.V344865.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Caroline House provides a well maintained environment for people to live in. Bedrooms are single and people are encouraged to personalise their rooms. EVIDENCE: Caroline House has been adapted over the years to meet the needs of people using the service, although it was not designed specifically for people who have additional physical disabilities. Over time, as the people who use the service needs change, further work may be required to meet their changing needs. The manager reported that work is in progress to see how these issues can be addressed. People have access to a lounge, kitchen/dining room and a large garden. One single bedroom with ensuite bathroom and toilet is on the ground floor. Four further single bedrooms, one bathroom with toilet and shower and one bathroom with toilet are on the first floor. People who use the service made positive comments including ‘I like my room’, ‘I’m comfy here’ and ‘I have all I Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 16 need in my room’. People were seen to be comfortable in the lounge and to have their belongings around them. An office on the ground floor with a small staff sleep in room on the first floor. One of the bathrooms was refurbished last year. People made positive comments about the new bathroom, in particular saying that they like the shower. The carpet in the entrance hall and lounge is stained. The manager reported that there are plans for these to be replaced this year. They also plan to buy new mattresses and to look at the front garden and how to improve its design. People who use the service confirmed that they are involved in choosing new carpets and furniture for their home. Progress has been made with providing radiator covers, with further work required for all radiators to be covered. The kitchen cabinets have been repaired but the manager reported that the cabinets will not be replaced until agreement has been reached over future plans for the home. Caroline House DS0000027207.V344865.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the service are happy with the care they receive. Staff receive appropriate training and support. Staff recruitment process meets regulations, however some further work is required to ensure full checks are completed. EVIDENCE: The published staff rota noted 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 seen to be adequate to meet peoples needs. Two questionnaires noted that staff ‘always’ and ‘usually’ have the skills and experience needed to meet peoples needs. Good relationships were observed between people who use the service and staff, with people making comments including ‘I like staff’ and ‘they help me’. Appropriate policies and practice are in place for the recruitment of staff. Staff files contained the required information including an application form, two written references, proof of the individuals identity and a job description. Gaps in employment had not been explored for one member of staff. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 18 New staff complete an induction which includes core training sessions, information about the organisation and the home. The organisation has a training and development plan and all staff have access to appropriate training. The home also makes use of training provided by the local authority. Two senior staff have completed NVQ to Level 3, with one member of staff going to start Level 3 in September 2007. One member of staff has completed NVQ to Level 2 with one member of staff working towards Level 2. The manager reported that staff receive supervision every eight weeks. Staff confirmed that they receive regular supervision and support. Staff also have an annual appraisal of their work, which identifies any areas for development and links to training courses. Caroline House DS0000027207.V344865.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager has the knowledge and experience to run the home. Good health and safety systems are in place with records in good order and required checks up to date. EVIDENCE: The manager has been at the home for a year and has developed systems to ensure staff receive regular supervision, that staff meetings and service user meetings take place regularly. Stakeholder surveys were completed last year and the manager reported that these are due to be sent out to relevant people in the near future. Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 20 A representative from the organisation visits every month and speaks with the people who use the service, staff and checks some records. A report is written with a copy at the home and one sent to the CSCI. The home holds some money for people who use the service, this is appropriately stored with up to date records. Two balances were checked and found to be correct, up to date and signed by staff. Appropriate policies, procedures and records are in place and up to date to ensure people who use the service, staff and visitors health and safety is maintained. The gas check was completed in September 2006, the bath hoist was tested in February 2007 and the fire alarm is tested weekly and serviced as required. The portable electrical appliances were checked in May 2006, this check must be completed every year. Caroline House DS0000027207.V344865.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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 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 3 3 X Caroline House DS0000027207.V344865.R01.S.doc Version 5.2 Page 22 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. Standard YA24 Regulation 12 (1) Requirement Timescale for action 18/10/07 2. YA42 12 (1) a The registered person must ensure that radiator covers are provided or radiators are replaced with low surface temperature type. (previous timescale of 30/03/07 not met) The portable electrical appliances 20/09/07 must be tested every year. 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 YA8 Good Practice Recommendations Consideration should be given to the use of a facilitator at service users meetings. 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