Inspection on 13/07/06 for Chertsey Road, 401

This inspection was carried out on 13th July 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 13/02/06

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 13th July 2006 1:15 401, Chertsey Road DS0000017356.V305771.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.V305771.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.V305771.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 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.V305771.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user over 65 years of age. 13th February 2006 Date of last inspection Brief Description of the Service: 401 Chertsey Road is home to five adults with learning disabilities. The service is operated by the Regard Partnership. Residents’ fees are calculated by care needs assessments. 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.V305771.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 wide range of sources when making judgements about the home. These included a visit to the home and discussion with residents, the manager and staff. A sample of records was examined, including staff and residents’ files. The inspector was made welcome during the visit and wishes to thank residents, staff and all those who gave their views about the home. The home met 25 of 27 National Minimum Standards assessed at this visit. Two Standards were almost met. The home had taken action to make sure that Requirements made at the last inspection had been met. Residents were busy and active during the inspection. Several residents attended day services and others went out with staff from the home. A musician visited the home during the inspection, a session that was clearly enjoyed by the residents who attended. There was one staff vacancy at the time of inspection. The manager and members of staff said that staff had supported one another well during this period. Staff also said that the manager is supportive and that the team communicates well. Allegations were made about one member of staff’s treatment of a resident before the inspection. The home acted appropriately following the allegations, informing all relevant parties and suspending the member of staff concerned. Once a disciplinary hearing had decided that the allegations were upheld, the member of staff was dismissed and referred to the Protection of Vulnerable Adults list. The inspection demonstrated that the staff team used this event to examine their own practice and to remind one another of the responsibilities that all staff have regarding the reporting of abuse. What the service does well: Provides good support for residents to lead individual lives. Involves and consults residents in the life of the home. Promotes residents’ participation in their community. Supports residents to access social and leisure opportunities. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 6 Supports residents to develop and maintain positive relationships with their friends and families. Provides a stable and committed staff team. Provides a skilled and experienced manager. 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. 401, Chertsey Road DS0000017356.V305771.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.V305771.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Information about the home is available to residents. Residents’ individual needs are assessed. EVIDENCE: The home has produced a Statement of Purpose, which gives details of the services and facilities provided and the aims and objectives of the service. A Service User Guide is available to all residents. Residents’ needs were assessed at the time of their admission. The manager stated that all residents will have a new care assessment in the near future, which will feed into newly developed care plan formats (see Standard 6). 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Staff understand residents’ individual needs. Residents are consulted about issues that affect them in the home. Residents receive good support to make informed choices about their lives. There is a commitment to supporting residents in taking manageable risks. EVIDENCE: An individual plan of care is in place for each resident, which is designed to identify individual skills, strengths, needs and goals. The manager advised that the home is in the process of introducing a new format for care planning. A sample of the new care plans was examined. It was noted that the care plans were incomplete in some areas (such as resident’s religion, for example) and that information was imprecise in other areas, such as guidelines for delivery of individual personal care. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 10 These observations were fed back to the manager, who advised that she plans to ensure all care plans are completed to the required standard once staff have prepared the first drafts. The manager expressed confidence that residents’ individual programmes reflect their interests and preferences. The manager stated that residents’ care plans are reviewed annually with the input of care managers, relatives and other relevant parties. The home performs internal care plan reviews at sixmonthly intervals. Observation during the visit confirmed that residents are able to choose the way in which they spend their time at the home. Residents are able to access advocacy services if they wish to do so. The manager and staff demonstrated a good knowledge of residents’ individual needs and a commitment to supporting residents in making informed decisions about their lives. There is also a commitment to implementing person-centred planning and an awareness of the need to balance residents’ rights and wishes with effective risk management. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents access day opportunities appropriate to their needs and preferences. Residents are involved in their local community. Residents are supported to develop and maintain relationships with their families and friends. Residents are consulted about the home’s menu. EVIDENCE: Residents access a range of day opportunities appropriate to their needs and preferences and are 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. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 12 Residents were involved in a number of activities on the day of inspection, including attending resource centres and going for walks and drives with staff support. All residents attend Whitton Community Resource Centre, which provides a range of in house activities and outings. Some activities take place at the home. The manager said that residents enjoy barbecues and using the garden and a musician visited during the inspection, a session that was clearly enjoyed by the residents who attended. Residents receive support from staff where necessary to maintain relationships with their friends and families. Interaction between staff on duty and residents was positive during the inspection. Residents have unrestricted access to all communal areas of the home. Residents’ wishes and needs are clearly identified in their individual plans. Staff used appropriate forms of address when speaking to residents. Residents are consulted about the home’s menu. Care staff have responsibility for cooking and preparing food, which is appropriate given the size of the home. Standards of food hygiene and storage at the time of inspection were good. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents are supported to access community and specialist healthcare resources where necessary. Changes in need are effectively identified and receive an appropriate response. Residents’ medication is appropriately stored and accurately recorded. EVIDENCE: The inspection provided evidence that healthcare conditions are managed effectively and that the home seeks specialist advice where necessary. The manager reported that the home has a good relationship with the local healthcare services and that community practitioners provide valuable support to the staff team. Due to behavioural and healthcare issues the home had recently consulted with professionals including general practitioners, the community psychologist, psychiatrist and speech and language therapist. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 14 Staff demonstrated a good awareness of residents needs. One member of staff reported that the team had noticed a reduction in some residents’ mobility and was able to demonstrate that appropriate professional input had been sought to address this issue. The minutes of team meetings also provided evidence that residents’ healthcare needs are discussed by the team in order that all staff adopt a consistent approach in their work with residents. Staff advised that some residents had been experiencing difficulties caused by the unusually hot weather and were able to describe the measures the home had taken to minimise these difficulties. 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. Individual medication records include residents’ photographs. Sample staff signatures are held on file. Inspection of medication records for three residents revealed no omissions or errors. No residents self-medicate. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Appropriate procedures are in place for the management of complaints. Appropriate guidance is provided for staff in the recognition, prevention and reporting of abuse. The home acted appropriately following recent allegations about the abuse of a resident. EVIDENCE: The home has an appropriate Complaints procedure. The CSCI received one complaint about the home since the last inspection and asked the Regard Partnership to investigate the allegations. The Regard Partnership conducted an appropriate investigation and reported its findings to the CSCI. The complaint was not upheld. The service works within the ‘Joint Policy on Suspected Abuse of Vulnerable Adults’. The Regard Partnership has a Whistle-blowing procedure, which enables staff to report any concerns about they have about poor practice. Allegations about one member of staff’s treatment of a resident were made during a recent holiday. The home acted appropriately following the allegations, informed all relevant parties and suspending the member of staff concerned pending disciplinary action. Following a disciplinary hearing, the 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 16 member of staff was dismissed and referred to the Protection of Vulnerable Adults list. Minutes of a recent team meeting demonstrated that the staff team used this event to examine their own practice and to reiterate the responsibilities that all staff have regarding the reporting of potential abuse. 401, Chertsey Road DS0000017356.V305771.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home is comfortable, safe and well maintained. The home is clean and hygienic. The communal areas of the home would benefit from redecoration. EVIDENCE: The home is situated in a pleasant residential area and has good access to local community facilities, open spaces and public transport networks. The property is adjacent to a busy road but trees bordering the garden give protection from the noise of passing traffic. Access to the home is gained to the rear of the property via a quiet residential street. The shared rooms on the ground floor of the home comprise two living rooms and a kitchen/diner. Communal rooms were welcoming and homely, although would benefit from redecoration. 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 18 There are enough toilets and bathrooms to meet residents’ needs. There is a large, well-maintained garden. All areas of the home were clean and hygienic. 401, Chertsey Road DS0000017356.V305771.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Job roles within the service are clear and defined. Systems of communication within the home are clear and effective. Staff receive effective induction, supervision and support. Staff are appointed following an appropriate recruitment and selection procedure. Staff are encouraged to attend training relevant to their roles, although some staff need to attend elements of mandatory training. EVIDENCE: The home has a clear staffing and management structure. Job descriptions and contracts of employment are in place for all posts within the staff team. The manager provides good individual support to staff and encourages good communication amongst the team. Handovers are given by staff finishing their shift to those beginning work. A communication book and house diary are 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 20 maintained. Team meetings are held on a regular basis and minutes are recorded. The home had one full-time staff vacancy at the time of inspection. This vacancy, allied to the fact that some of the home’s regular bank staff were unavailable and some staff sickness, has led to high demands on the permanent staff team. The manager and members of staff said that staff had supported one another well during this period and were confident that the service provided to residents had not been affected. Examination of staff files provided evidence of an appropriate recruitment procedure and pre-employment checks, including Criminal Records Bureau disclosure. Staff files also demonstrated that staff receive an induction when they start work, regular supervision and an annual appraisal. Staff spoken to during the inspection reported that they are encouraged to attend training relevant to their roles. A number of staff are registered on NVQ courses. However records indicated that some staff need to attend elements of mandatory training. In some cases, staff had attended relevant courses, but needed to attend refresher training. See Requirement 1. 401, Chertsey Road DS0000017356.V305771.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home has a skilled and experienced manager. The manager provides good leadership and guidance. Staff are committed to running the home in residents’ best interests. There is a commitment to maintain the health and safety of residents and staff. The home’s fire risk assessment must be reviewed. EVIDENCE: The manager has significant experience in her role and has a commitment to the continuous improvement of the service. Staff spoke to during the 401, Chertsey Road DS0000017356.V305771.R01.S.doc Version 5.2 Page 22 inspection said that the manager provides good support to staff. One member of staff said that the manager is “approachable”, whilst another member of staff said that the manager is “a good listener”. Discussion with the manager and staff confirmed that there is commitments to running the home in the best interests of residents and to ensuring residents’ wishes are met wherever possible. 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. Accident/incident records were accurate and up-to-date. The home has valid Employers Liability Insurance. Staff perform a weekly health and safety check that covers all areas of the home and identifies any potential hazards. The last health and safety check on file was dated 7 July 2006. A fire safety audit conducted in July 2006 checked the home’s fire fighting equipment, fire exits and emergency lighting. A fire drill was also carried out on this date. The home’s fire risk assessment states that a review of this assessment should be carried out in March 2006. However there was no evidence that a review had taken place. See Requirement 2. 401, Chertsey Road DS0000017356.V305771.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 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 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 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 X 2 X 401, Chertsey Road DS0000017356.V305771.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. 1 Standard YA35 Regulation 18(1) Timescale for action Ensure that all staff have 30/09/06 attended elements of mandatory training, including refresher courses where necessary. Review the home’s fire risk 30/08/06 assessment. Requirement 2 YA42 23(4) 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 YA24 Good Practice Recommendations Redecorate the communal areas of the home. 401, Chertsey Road DS0000017356.V305771.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: 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.V305771.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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