Inspection on 13/02/06 for Chertsey Road, 401

This inspection was carried out on 13th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chertsey Road, 401 12/09/07

Chertsey Road, 401 13/07/06

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 13th February 2006 9:30 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 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.V286414.R01.S.doc Version 5.1 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.V286414.R01.S.doc Version 5.1 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 The Regard Partnership Limited Ms Maureen Lloyd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: 401 Chertsey Road is owned and operated by the Regard Partnership. The Regard Partnership is an established not-for-profit provider of residential and community services for people with learning disabilities. Opened in 1997, the home is registered with the CSCI for the provision of care to five adults with learning disabilities. The service has no vacancies at present. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over the course of a single visit and involved speaking to residents, the manager and members of staff. A sample of records was examined and a tour of the building made. The inspector was made welcome and wishes to thanks residents and staff for their help during the inspection. The home met 21 of 23 National Minimum Standards assessed at this visit. Two Standards were almost met and two Requirements were made. The home was fully staffed at the time of inspection. One of the strengths of the service is that the manager and staff have worked there for some time. As a result, residents are cared for by people who know them and their needs well. Staff receive good support to do their jobs and have access to appropriate training. New staff receive a good induction when they start work. Residents are encouraged to use their local community and are consulted about the life of the home. Relatives gave positive feedback about the home in a recent Quality Assurance survey conducted by the Regard Partnership. Relatives praised the support residents receive to achieve progress and personal development. What the service does well: What has improved since the last inspection? The deputy manager has attended person-centred planning training. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 6 Residents have tried a number of new activities through day opportunities programmes. The home has a new computer and internet access. A National Vocational Qualification (NVQ) assessor is now regularly available to staff. Staff working towards National Vocational Qualifications now have regular access to support from an assessor. 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. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 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.V286414.R01.S.doc Version 5.1 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, 3 Residents’ strengths and needs are effectively identified. Residents receive good support to achieve their goals and aspirations. Staff liaise effectively with other professionals and relatives where necessary. Staff have the qualities and skills needed to support residents. EVIDENCE: The home is registered to accommodate residents between the ages of 18 and 65 years. The manager advised that one resident has reached the age of 65. The Registered Person must therefore submit an application to the CSCI to vary the home’s registration category. See Requirement 1. Residents’ needs are effectively identified through the assessment process and residents receive support to access specialist services where necessary. The home is committed to developing individual plans that are person-centred and reflect residents’ needs and aspirations. Staff liaise effectively with other professionals and seek the input of relatives where appropriate. The design and layout of the home meets the needs of those who live there. Staff know residents well and have the qualities and skills needed to support them. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 10 Care plans reflect residents’ individual needs, aspirations and preferences. Residents receive good support to make informed choices about their lives. Residents are consulted about issues that affect them. Confidential information is stored and handled appropriately. EVIDENCE: Each resident has an individual care plan, which records their strengths, needs, likes and dislikes and preferences in terms of routine. Goals and aspirations are recorded and the support needed to achieve these objectives is identified. Residents meet each month with their keyworker and the manager to monitor progress against agreed goals. These goals form part of each resident’s care plan. Some goals focus on short term objectives whilst others address more long term issues. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 10 The deputy manager has attended four day person-centred planning training since the last inspection. The manager reported that, whilst residents’ care plans had not changed greatly since the introduction of person-centred planning, the approach had proved useful in improving the monitoring of residents’ care plans. All the care plans examined had been recently reviewed. Staff have a commitment to involving residents in the life of the home and promoted choice and individual responsibility during their interactions with residents during the inspection. Staff have a good awareness of residents’ needs and preferences and use this knowledge to provide appropriate support. Staff interacted positively with residents during the inspection, providing meaningful engagement and encouraging residents to participate in activities appropriate to their needs. Residents’ meetings are held once a fortnight. The manager said that the group often discuss activities they might like to try, the menu or holiday options. The manager said that residents are also encouraged to use these forums to raise any concerns they may have. Staff feed back to residents on any actions taken since the previous meeting. The Regard Partnership has a ‘Confidentiality’ policy. The policy sets out clear guidelines for staff concerning the storage, access, handling and usage of confidential information and complies with the Data Protection Act (1998). All sensitive information was stored appropriately. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Residents receive good support to access their local community and take part in stimulating activities. Residents receive good support to develop friendships and to maintain contact with their relatives. The home’s menu is varied, well balanced and takes account of residents’ needs. EVIDENCE: Residents attend a variety of day services according to their needs and preferences. All residents attend Whitton Community Resource Centre, which provides a range of in house activities and outings. The manager reported that residents have tried several new activities through the resource centre since the last inspection. including companion cycling. One resident out for walk at the time of inspection. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 12 Residents are actively involved in their local community. Whitton high street is within walking distance of the home and residents make use of local shops, banks, cafes and pubs. One resident attends church on a weekly basis. Residents receive good support to develop friendships and to maintain contact with their relatives. All residents have some family contact. Residents are supported to maintain contact with relatives who are unable to visit the home. Staff keep relatives informed about events affecting residents. The input of residents’ relatives is sought at reviews. Relatives gave very positive feedback about the home in a recent Quality Assurance survey conducted by the Regard Partnership. Relatives praised the support residents receive to achieve progress and personal development. Interactions between staff and residents was positive during the inspection. Residents have unrestricted access to all communal areas of the home and are able to have privacy when they want it. Residents’ wishes and needs are clearly identified in their individual plans. Staff used appropriate forms of address when speaking to residents. Responsibility for cooking and preparing food is shared amongst the staff team. All staff undertake basic food hygiene training when they start work. The home’s menu indicated that residents receive a varied and well-balanced diet. Staff reported that residents are encouraged to contribute to menu planning, particularly during residents’ meetings. Snacks and drinks are available to residents at any time. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Residents receive good support to access community and specialist healthcare resources where necessary. Changes in need are effectively identified and receive an appropriate response. Standard of medication administration and recording must improve. EVIDENCE: All residents are registered with local general practitioners and access other community healthcare resources as necessary. Staff on duty demonstrated a good knowledge of residents’ healthcare needs and an awareness of individual guidelines for delivering care. The inspection provided good evidence that any changes in residents’ needs are effectively identified and that staff respond appropriately to these changes. For example, the manager was able to demonstrate that the home is seeking to identify any changes in residents’ needs due to aging. The advice of healthcare professionals is sought where appropriate. The manager reported that a psychologist visits the home once a month to work 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 14 with residents and to provide guidance to the staff team. One resident currently meets with a psychiatrist every three to six months. There is an appropriate system for the storage and administration of medication. All medication coming into or leaving the home is recorded. There are clear protocols governing the administration of medication. There are no residents who self medicate. Sample signatures for staff who administer medication are held on file. Medication Administration Records contain photographs of residents. Inspection of a sample of medication indicated that medication from one resident’s monitored dosage system (MDS) had been incorrectly removed. See Requirement 2. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 15 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 Training and guidance is provided for staff in the recognition, prevention and reporting of abuse. EVIDENCE: The home works within the framework of the local authority‘s ‘Joint Policy on Suspected Abuse of Vulnerable Adults’. The most recent Protection of Vulnerable Adults (POVA) training for staff took place in October 2005. The manager said that the Regard Partnership has a commitment to providing this training on a regular basis and has three in house trainers who can deliver training in this area. Appropriate pre-employment checks are carried out on new staff before they start work. (See also Standard 34). 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 The home is comfortable, safe and well maintained. Communal rooms are welcoming and homely. Residents’ bedrooms reflect individual preferences. 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 high standard of decoration has been achieved throughout the home and the property has a large, well-maintained garden. The property is adjacent to a busy road but trees bordering the garden give protection from the noise created by passing traffic. Access to the home is gained to the rear of the property via a quiet residential street. Shared rooms include two lounge areas and a kitchen/dining room. The communal rooms of the home were welcoming and homely and bedrooms reflected residents’ tastes and preferences. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 17 The manager said that the lounge carpet is due for replacement and that the kitchen/dining room and hall will be redecorated in the near future. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 There is a stable staff and management team who know residents and their needs well. There is appropriate support for staff working towards National Vocational Qualifications. Staff receive a good induction when they start work and have access to regular supervision and support. EVIDENCE: The home was fully staffed at the time of the visit. No staff had left the home or joined the staff team since the last inspection. As a result, residents are cared for by staff who know them well. The manager said that the home has bank staff available to cover vacant shifts if needed. Staff meetings are held every two weeks. Notes of the most recent meeting demonstrated that meetings are used to ensure that staff have up to date information about residents and their needs. The manager feels that staff “support one another well” and have a positive approach to training and development. Staff spoken to on the day of inspection reported that they receive regular supervision and good support to perform their jobs. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 19 The last inspection report made a Requirement that staff working towards National Vocational Qualifications have regular access to an approved assessor. The manager reported that an assessor has been identified and has visited the home regularly to work with staff. Three staff files were examined. All provided evidence of an appropriate recruitment procedure and appropriate pre-employment checks including Criminal Records Bureau disclosure, proof of identity and written references. Files also demonstrated that staff receive a good induction when they start work and have access to regular supervision. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 20 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): 39, 42, 43 The home aims to seek and respond to residents’ views. The health and safety of residents and staff within the home is maintained. The home is managed effectively. EVIDENCE: The home aims to seek residents’ views through regular meetings, which are supported by staff. Residents are encouraged to involve themselves in the routines of the home and are consulted about decisions in the home that affect them. (See also Standard 8). The home has an appropriate fire detection system, which is tested regularly by staff. The home’s fire fighting equipment is checked annually. Clear instructions for use in the event of a fire were prominently displayed. 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 21 The home was clean, hygienic and free of obvious health and safety hazards on the day of inspection. Standards of food storage were satisfactory. All substances potentially harmful to health (COSHH products) were stored appropriately. The home maintains an Accident book. There is a clear procedure to be followed should a resident go missing. The manager has access to line management support from the Director in the absence of an Area Manager at present. The supported by the central services of the Regard Partnership where The service is regularly monitored by the organisation’s Quality officer. The home has valid Employers Liability insurance. Operations service is necessary. Assurance 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 22 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 X 2 3 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X 3 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 X 3 2 X X X 3 X X 3 3 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 23 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. 1 2 Standard YA3 YA20 Timescale for action Section 24 The Registered Person must 30/03/06 CSA submit an application to vary the (2000) home’s registration category. 13(2) The Registered Person must 30/03/06 ensure that the administration and recording of medication is accurate. Regulation Requirement 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.V286414.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 401, Chertsey Road DS0000017356.V286414.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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