Inspection on 12/09/07 for Chertsey Road, 401

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chertsey Road, 401 13/07/06

Chertsey Road, 401 13/02/06

Chertsey Road, 401 08/09/05

Chertsey Road, 401 03/02/05

Chertsey Road, 401 02/06/04

Chertsey Road, 401 27/01/04

Chertsey Road, 401 02/10/03

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 18-65 401, Chertsey Road Whitton Middlesex TW2 6LS Lead Inspector Simon Smith Unannounced Inspection 12th September 2007 9:30 401, Chertsey Road DS0000017356.V347707.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 401, Chertsey Road DS0000017356.V347707.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. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 401, Chertsey Road Address Whitton Middlesex TW2 6LS 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) 020 8894 4321 020 8894 4321 chertsey@regard.co.uk The Regard Partnership Ltd Ms Maureen Lloyd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2006 Brief Description of the Service: 401 Chertsey Road is home to five adults with learning disabilities. The service is operated by the Regard Partnership. Current fees range from £1350 to £1800 per week. The Regard Partnership is a not-for-profit provider of residential and community services for people with learning disabilities and operates a number of other, similar services in the surrounding area. The home is situated in a pleasant residential area and has good access to public transport networks and shopping and community facilities. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector used evidence from a range of sources when making judgements about the home. These included visiting the home and talking to residents, staff and the manager. Some written information was checked, including staff and residents’ files. The inspector was made welcome during the visit and wishes to thank all those who gave their views about the home. The home met 25 of 31 National Minimum Standards assessed at this visit. Six Standards were exceeded. Two staff were on duty during the inspection. Both had worked at the home for several years. One resident had gone on a day trip with a resource centre for the day and one resident went out with a member of staff during the visit. One resident told the inspector that she planned to go out later in the day with a member of staff and that she was looking forward to her holiday. What the service does well: What has improved since the last inspection? The home has made good use of symbols and accessible information to involve residents in decisions that affect them. Written information has been made more accessible to residents. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 6 All information on residents’ care plans has been updated. The home now sends surveys to all stakeholders regularly. Some parts of the home have been redecorated. 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. 401, Chertsey Road DS0000017356.V347707.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 401, Chertsey Road DS0000017356.V347707.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written information about the home is available to residents. Residents’ needs are effectively assessed. The home has a clear Admissions procedure. Residents are issued with a contract that sets out the terms and conditions of residence. EVIDENCE: The home has produced a Statement of Purpose and a Service User Guide. Both these documents have been updated since the last inspection and made more accessible to residents. The Statement of Purpose sets out the home’s aims and objectives and the Service User Guide outlines residents’ rights and responsibilities. There was an up to date contract on file for each resident, which sets out the terms and conditions of residence. Care plans contained comprehensive assessments of residents’ needs and strengths. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 9 There is a clear procedure for the admission of new residents, although there have been no changes in the resident group for some time. The home’s Admissions procedure includes a six week trial followed by a review and another review at six months. This process is clarified in the Service User Guide. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 10 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): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have an up to date care plan. Care plans record residents’ needs and strengths and provide guidance for staff delivering care. Residents receive good support to make choices about their lives. The home supports residents in taking manageable risks. EVIDENCE: The home had introduced new care plans since the last inspection and updated the information held about residents. The new care plans checked contained an individual profile and good information about residents’ strengths, needs and preferences. The manager said that all residents have annual reviews with 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 11 their care managers. Individual risk assessments were incorporated into residents’ care plans. Staff demonstrated a good knowledge of residents’ needs and a commitment to supporting residents in making decisions about their lives. Residents were supported to make choices about how they spent their time during the inspection and are consulted about decisions that affect them. The service consults significant others, such as family members and care managers, where appropriate about residents’ care. (See also Standard 39). 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ have individual programmes that reflect their needs and interests. Residents are involved in their local community. Residents receive good support to maintain relationships with their friends and families. Residents’ rights and responsibilities are recognised in their daily lives. Residents are consulted about the home’s menu and receive a balanced diet. EVIDENCE: 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 13 Residents lead busy lives and receive good support to access a range of opportunities. Four residents use a local resource centre regularly. These residents have a linkworker at the resource centre who liaises with the home about residents’ programmes. The manager said that the resource centre has adopted a person centred approach, which has been reflected in residents’ individual programmes. One resident is currently choosing not to attend day services. The manager has applied to the resident’s funding authority for additional funding to pay for one-to-one staff support. Residents go out a lot and are involved in their local community. Most residents go to church and the manager said that they know many people through their attendance. Residents also receive good support to maintain positive relationships with their friends and families. The manager gave an example of how one resident had recently been supported to revive an old friendship with someone she had known many years ago. Interaction between staff and residents was positive during the inspection. Residents’ wishes and needs are clearly identified in their individual plans. Staff used appropriate forms of address when speaking to residents. Residents’ rights and responsibilities are recognised in their daily lives. The menu indicated that the home provides a varied and well-balanced diet. Residents are able to contribute to the home’s menu and staff said that some residents choose to involve themselves in mealtime routines such as food preparation and setting the table. The home has a kitchen/diner, which is the focus of socialising around meal times. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive good support to access community and specialist healthcare resources. Changes in need are effectively identified and receive an appropriate response. The home seeks the advice and input of other professionals where necessary. Medication is appropriately stored and accurately recorded. EVIDENCE: The inspection provided evidence that the home liaises well with healthcare professionals when necessary and responds appropriately to any changes in residents’ needs. For example one resident, who lost a lot of weight in a short period of time, had input from a dietician in the local community team. The manager said that the dietician remains involved with the resident’s care, monitoring information recorded by staff at the home. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 15 The manager said that the home has “a good rapport” with the local community team and that they provide useful guidance for staff delivering residents’ care. The manager advised that the community nurse plans to draw up an individual Health Action Plan for each resident in the near future. There is an appropriate system for storing medication and there are clear, written procedures governing the administration of medication. Medication records for three residents were checked and found to be accurate. No residents self medicate. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear Complaints procedure. Training is provided for staff in the recognition, prevention and reporting of abuse. EVIDENCE: The home has a Complaints procedure. There have been no complaints about the home since the last inspection. The Regard Partnership has a Whistleblowing procedure, which enables staff to report any concerns about they have about poor practice. The home works within the ‘Joint Policy on Suspected Abuse of Vulnerable Adults’, which provides guidance for staff in the recognition and reporting of abuse. The manager said that all staff have had recent training in the Protection of Vulnerable Adults. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 17 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): Standards 24, 25, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and well decorated. The communal rooms of the home are welcoming and homely. Residents’ bedrooms reflect individual preferences. The home is clean and hygienic. EVIDENCE: The home is situated in a pleasant residential area and has good access to local community facilities, open spaces and public transport networks. A good standard of decoration has been achieved throughout the home and the property has a well-maintained garden. Some communal parts of the home have been redecorated since the last inspection. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 18 The communal rooms include two lounges and a kitchen/dining room on the ground floor. One bedroom is situated on the ground floor and the remainder on the first floor. Bedrooms vary in size and layout due to the design of the home but all are personalised and reflect the tastes and preferences of their occupants. All areas of the home were clean and hygienic. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 19 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): Standards 31, 32, 33, 34, 35 and 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Job roles within the service are clear and defined. Staff communicate effectively with one another and share information well. Staff are appointed following an appropriate recruitment procedure. Staff attend training appropriate to their roles. Staff receive good supervision and support. EVIDENCE: The manager and most staff have worked at the home for some time and know residents well. Staff work to a clear shift plan, which ensures that staff know their responsibilities that day. There is also a nominated shift leader for each shift. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 20 The manager said that staff work well together as a team and support one another. There was one full-time vacancy at the time of inspection. The manager said that permanent staff were covering vacant shifts, although the home was in the process of recruiting to the post. Staff records provided evidence of a thorough recruitment procedure and that the Regard Partnership carries out appropriate pre-employment checks on staff, including Criminal Records Bureau disclosures. The manager said that all staff were up to date with core training. The manager said that the Regard Partnership had recently launched a new induction programme for staff, which is designed to meet the Skills for Care Common Induction Standards. All staff have regular individual supervision and an annual appraisal. Staff meet as a team regularly. Each key worker talks about their clients at these meetings and updates all staff on any changes. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 21 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): Standards 37, 38, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a skilled and experienced manager. The manager provides good leadership and guidance. There is a commitment to seeking residents’ views and to acting on what residents say. The home regularly seeks the views of appropriate stakeholders. The health and safety of residents and staff is maintained. EVIDENCE: 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 22 Systems of administration are clear and well organised. The manager has significant experience in her role and is committed to the continuous improvement of the service. The manager also provides good support and leadership to the staff team. The manager and staff are committed to running the home in residents’ best interests and to seeking their views about issues that affect them. Residents meetings are held each month, supported by staff. These meetings are used to seek residents’ views about activities, menus and any other issues they wish to raise. Residents are also encouraged to discuss any concerns or complaints they may have at these meetings. Staff use pictorial aids to assist residents’ understanding of the issues under discussion. Notes of residents’ meetings demonstrated that residents use this forum to talk about issues that are important to them and that staff feed back on issues raised at previous meetings. The manager said that the home now distributes surveys to stakeholders, including residents’ relatives, healthcare professionals and care managers, each quarter. The most recent surveys returned to the home provided good feedback about the quality of the service, particularly the care provided by staff and the homely environment. Staff carry out a weekly health and safety check. Records of these checks were up to date at the time of inspection. The home’s fire risk assessment has been reviewed since the last inspection. Staff test the alarm system weekly, using different call points. The fire alarm system was serviced in August 2007 and the fire fighting equipment serviced in July 2007. The last fire drill was held in August 2007. 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 23 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 3 5 3 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 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 4 34 3 35 3 36 4 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 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 4 4 X X 3 X 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 401, Chertsey Road DS0000017356.V347707.R01.S.doc Version 5.2 Page 26 - 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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