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Inspection on 24/06/05 for Caroline House

Also see our care home review for Caroline House for more information

This inspection was carried out on 24th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A homely environment is provided for residents with suitable furnishings and fittings. The few permanent staff have been at the home for a few years, providing consistency of care for residents.

What has improved since the last inspection?

A new fridge has been installed in the kitchen ensuring food is safely stored. Three new staff have been appointed at the home which will improve the consistency of care for residents and reduce the need for agency staff at the home. These issues were Requirements made at the last inspection of the home. The garden has been tidied and cleared around the edges and looks far more appealing for residents to use.

What the care home could do better:

Care plans should be up to date to reflect residents changing needs to ensure staff are aware and can meet them. An appropriate activities programme should be developed for one resident to ensure that their social and educational needs are met. The kitchen cabinets require repairing or replacing to ensure that the environment is maintained at a satisfactory standard for residents. Policies and procedures should be updated to include informing the CSCI and have the date included. The fire alarm must be tested for safety reasons.

CARE HOME ADULTS 18-65 Consfield Avenue 114 Consfield Avenue New Malden Surrey KT3 6HE Lead Inspector Emma Dove Unannounced 24 June 2005 11:30am and 30 June 2005 4:40pm th th 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 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 Stationary 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. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Consfield Avenue Address 114 Consfield Avenue New Malden Surrey KT3 6HE 0208 336 2600 0208 336 2600 Telephone number Fax number Email 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 CRH Care Home 5 Category(ies) of LD Learning Disability (5) registration, with number of places Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/02/05 Brief Description of the Service: 114 Consfield Avenue 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, 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 Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 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 three hours, one morning and two hours one evening by one inspector. The inspection consisted of examination of records, inspection of communal areas of the home, inspection of one residents bedroom, talking to residents and staff. The inspector had the opportunity to speak with four residents, three members of staff and the line manager for the home. What the service does well: What has improved since the last inspection? What they could do better: Care plans should be up to date to reflect residents changing needs to ensure staff are aware and can meet them. An appropriate activities programme should be developed for one resident to ensure that their social and educational needs are met. The kitchen cabinets require repairing or replacing to ensure that the environment is maintained at a satisfactory standard for residents. Policies and procedures should be updated to include informing the CSCI and have the date included. The fire alarm must be tested for safety reasons. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 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. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 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 standard(s) 1 Prospective residents would receive information regarding the home and the services provided, enabling them to make an informed choice regarding moving into the home. EVIDENCE: A Statement of Purpose and Service Users Guide to the home are in place, enabling prospective residents to make an informed choice regarding moving into the home. This information would be given to prospective residents, their relatives or representatives and placing social workers. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 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 standard(s) 6 & 8 Residents needs are appropriately assessed and developed into a care plan. EVIDENCE: Care plans are in place which are kept under review, ensuring their needs are recorded and can be met by staff. Residents are involved in developing their care plans. Staff reported that the home is moving towards developing Person Centred Plans for residents, which will include more detailed information of residents needs. This will ensure residents needs are fully met. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 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 standard(s) 11, 12, 13 & 14 Four residents social and educational needs are met through accessing a variety of day centres, clubs and groups during the week and evenings. One resident does not attend regular groups or activities and their educational needs are not being fully met at the home. EVIDENCE: Residents are assisted and supported by staff in all areas of independence and self help, including meal preparation, cleaning and household tasks and with personal care. Four residents attend various day centres, depending on their needs and interests four days a week, one resident remains at the home weekdays, a programme is being developed to meet their needs. Two residents made positive comments regarding their daily activities, saying they ‘enjoy the day centre’ and they ‘like seeing their friends’. Residents are able to pursue religious observance. A car is available at the home to assist with residents accessing community facilities. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 11 The first day of the inspection three residents were away on holiday. On the second inspection visit, residents confirmed they had been involved in choosing the holiday. One resident said that the holiday was ‘very good’. Residents are enabled to maintain contact with family and friends by staff at the home. Visitors are welcome at the home. The home has recently been given a name, ‘Caroline House’ and a special naming ceremony was held at the home, which staff reported was a successful party day for everyone. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Residents privacy and dignity are maintained and residents receive appropriate support to meet their needs. EVIDENCE: Residents and staff reported that assistance with personal care tasks is completed in private. Residents receive support from a female staff team, which meets their needs. Residents confirmed that there are no set times for going to bed and they get woken depending on transport times for attending day centres in the morning. The home operates a key work system, two residents were aware of who their key worker is. One resident has an advocate who visits the home regularly, this offers the resident a person outside of the organisation to speak with. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Residents welfare is protected by the complaints procedure. EVIDENCE: The organisation has a complaints procedure which is included in the Statement of Purpose and Service Users Guide to the home. Residents did not raise concerns about the care that they receive. Two residents said that they would speak to the manager regarding any concerns they have. No complaints have been received by the CSCI. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26 & 28 The home provides a homely and comfortable environment for residents. EVIDENCE: The home has been developed and extended to meet the needs of current residents. The home is in keeping with neighbouring houses and is not easily identifiable as a care home. The home provides homely and comfortable accommodation to meet residents needs. Staff reported that plans for future developments at the home are underway to ensure residents changing needs can be met. The plans include an extension to the home providing a bedroom, pending planning permission. All bedrooms are single. One resident made positive comments regarding their bedroom and said that the best thing about their room is the window, the view and having their own belongings and memorabilia around them. Residents have access to a lounge with doors to the garden and a kitchen/dining room. The kitchen cabinets are in need of repairing or replacing to ensure the environment is maintained at a satisfactory standard. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 33 Residents needs are met by a small dedicated core group of longstanding staff who demonstrate detailed knowledge of residents needs and how to meet them, providing consistency of care to individuals. EVIDENCE: Three permanent staff are currently employed at the home with two new staff waiting recruitment checks prior to commencing employment at the home. The commitment of the current permanent staff has been positive regarding meeting residents needs, however this small number of permanent staff is not sufficient to ensure residents receive consistency of care. Four members of staff are employed through the organisations care bank on a part time basis to cover vacant positions, staff training, annual leave and sickness, this works towards consistency of care for residents. Two members of staff are 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. On the first inspection visit, one member of staff was on duty at the home with two residents. A risk assessment should be completed for when one member of staff is alone at the home to ensure residents welfare is maintained. Staff meetings are held every three to four months with records maintained. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40 & 42 Policies and procedures are in place to protect and promote residents health and welfare, however some policies require updating. The fire alarm has not been tested weekly which does not ensure residents safety is maintained. EVIDENCE: Residents health and welfare is promoted by policies and procedures in place at the home, however some policies require updating to include details of the CSCI and to reflect recent changes in legislation to ensure residents welfare is fully protected. The fire alarm system has not been tested weekly by staff, which does not ensure residents and staffs safety. Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 2 x x Standard No 11 12 13 14 15 16 17 3 2 3 3 x x x Standard No 31 32 33 34 35 36 Score 3 x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Consfield Avenue Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x x 2 x 2 x G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 18 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 6 Regulation 15 (1) Requirement The registered person must ensure that care plans are up to date and that Person Centred Plans are developed for all residents. The registered person must ensure that an appropriate programme is developed to meet one residents social and educational needs. The registered person must ensure that the kitchen cabinets are repaired or replaced. (timescale of 12/05/05 not met) The registered person must ensure that policies and procedures are reviewed and updated to take into account changes in legislation. The death, missing persons and accident procedures require updating to include informing the CSCI. The disciplinary and whistle-blowing procedures require dating. (timescale of 12/05/05 not met) The registered person must ensure that the fire alarm is tested weekly with records maintained for inspection. (timescale of 12/05/05 not met) Timescale for action 24/08/05 2. 12 16 (2) m &n 24/08/05 3. 28 16 (2) g & 23 (2) c 12 (1) 24/08/05 4. 40 24/08/05 5. 42 23 (4) c (iv) 24/08/05 Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 19 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 Good Practice Recommendations Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon 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 Consfield Avenue G54-G04 S27207 Consfield Avenue V240132 240605 stage 4.doc Version 1.40 Page 21 - 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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