Inspection on 08/09/05 for Chertsey Road, 401

This inspection was carried out on 8th September 2005.

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 3 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 13/02/06

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 Chertsey Road, 401 Whitton Middlesex TW2 6LS Lead Inspector Simon Smith Unannounced Inspection 8th September 2005 12.00p Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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.very.uk Internet address Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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, VERY3 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. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chertsey Road, 401 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 Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 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. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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 afternoon and involved discussion with residents, the manager, the deputy manager and members of the staff team. A sample of records was examined and a tour of the premises made. The inspector was made welcome throughout the visit and wishes to acknowledge the time and consideration that residents and staff provided during the course of the inspection. The home met 28 of 30 National Minimum Standards assessed at this visit. Two Standards were almost met. An individual plan is in place for each resident, which reflects individual strengths, needs and wishes. Residents participate in a range of activities according to their needs and preferences. In addition to day services, residents take part in social and leisure activities, outings and holidays. Residents enjoy a high level of involvement in their local community and receive good support from staff to achieve this where necessary. All residents are registered with local doctors and staff ensure that residents receive specialist advice or treatment when they need it. The home is situated in a pleasant residential area and is close to local banks, cafes, public transport and open spaces. The communal rooms home were welcoming and homely and bedrooms reflected residents’ and preferences. Residents are able to have privacy when they want appeared comfortable and confident in their environment. shops, of the tastes it and Systems of recording and administration within the home are clear and well maintained. Staff work within written guidelines and a clear procedural framework. The manager and several of the staff team have worked at the home for some time. As a result, residents are cared for by staff who know them and their needs well. The manager is experienced and provides appropriate leadership to the staff team. New staff are recruited according to written policies and the home carries out appropriate checks before they start work. New starters also attend induction and core training and all staff receive good support and supervision in their work. What the service does well: Identifies residents’ accordingly. needs effectively and delivers care and support Promotes residents’ participation in their community. Provides opportunities for residents to access a wide range of social and leisure activities. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 6 Supports residents in maintaining contact with their families and friends. Enables access to specialist resources where necessary to meet residents’ needs. Encourages residents. and promotes effective communication amongst staff and Provides good induction, supervision and support to enable staff to do their jobs. 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. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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 Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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’ needs and strengths are effectively identified. Residents receive good support to achieve their goals and aspirations. Staff liaise effectively with other agencies and professionals where necessary. EVIDENCE: Care plans indicated that residents’ needs are effectively identified through the assessment process and that this information forms the basis of care and support delivered. The home is committed to ensuring that individual plans are person-centred and reflect the needs and aspirations of residents. Staff liaise effectively with other agencies and residents receive support to access specialist services where necessary. The design and layout of the home meets the needs of those who live there. Adaptations and specialised equipment have been installed where necessary to improve mobility. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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, 10 Individual plans are regularly reviewed and reflect residents’ needs and aspirations. Residents receive good support to make informed choices about their lives. Risk factors are effectively identified and managed. All sensitive and/or confidential information is stored securely within the home. EVIDENCE: An individual plan of care is in place for each resident. A standard format is used for this purpose and the standard of recording was found to be good. Care plans record residents’ strengths, needs, likes and dislikes across a range of areas. Care plans also include a ‘pen portrait’ of each resident and a missing persons profile. The input of any community healthcare professionals involved in the resident’s care is also recorded. Examination of two residents’ files indicated that care plans are subject to regular review. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 10 One resident had a six-month review on the day of inspection, attended by the resident, her keyworker and the deputy manager. The inspector was able to speak to those taking part about the review process. Comments from all those involved demonstrated that the resident was now taking part in activities she enjoyed more regularly and that she was pleased with this outcome. Whilst this confirms the value of the review process, and that the home is meeting the resident’ needs, staff should aim to be more specific in recording identified goals and progress made in achieving them. Some sections on residents’ reviews relating to specific objectives, timescales and the person responsible for action were incomplete. Improvements in this area should realise benefits in terms of the ability to review and assess progress towards the resident’s identified individual goals. Staff demonstrated a good knowledge of residents’ individual needs and a commitment to supporting residents in making informed decisions about their lives. Observation confirmed that residents are able to choose the way in which they spend their time at the home. The service consults significant others, such as family members and care managers, where appropriate regarding the care of residents. All residents have an allocated keyworker. Staff receive training in this role prior to keyworking residents. The manager reported that residents’ keyworkers are changed annually in order that staff get to know all residents well. The Regard Partnership provides appropriate guidance for staff in the identification and management of risk. Risk assessments are in place addressing specific activities undertaken by residents. These assessments are subject to regular review. The Regard Partnership has a ‘Confidentiality’ statement, to which all staff are expected to work and which complies with the Data Protection Act (1998). All confidential or sensitive information was found to be stored appropriately within the home. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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, 14, 15 Residents participate in a range of social and leisure activities appropriate to their needs and preferences. Staff are committed to supporting residents in achieving high levels of community participation. Residents receive good support to develop and maintain relationships with their families and friends. EVIDENCE: Resident participate in a range of activities appropriate to their needs and preferences. One resident attended in-house activities at a resource centre on the day of inspection whilst another took part in a day trip organised by the resource centre. Resource centre staff also visit the home to work with residents. One member of staff from the resource centre visited on the day of inspection to go for walk with a resident. Staff from the home are encouraged to support residents in their community and residents make use of local shops, Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 12 banks, cafes, hairdressers and other resources. One resident attends church on a weekly basis. Care plans provided evidence that residents attend social clubs and events in their spare time and staff reported that all residents have regular contact with their families. Residents are encouraged to celebrate birthdays and other occasions with parties at the home. All residents have at least one holiday each year. Staff on duty explained that holidays are arranged according to residents’ preferences, which are discussed by the resident and their keyworker. Four residents had taken their annual holiday at the time of inspection, whilst one was due to go on holiday in the near future. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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 Care staff have a good awareness of residents’ emotional and healthcare needs. Residents receive good support to access community and specialist healthcare resources where necessary. EVIDENCE: Care plans identified residents’ individual support needs and contained guidance for staff delivering care. All healthcare appointments are recorded. Residents are registered with local general practitioners and specialist advice is sought from community healthcare professionals to address residents’ needs where necessary. The manager reported that a psychologist visits the home once a month to work with residents and to provide advice and guidance to the staff team. One resident currently meets with a psychiatrist every three to six months. Two residents see a dietician regularly. One service user had had a fall in the week prior to inspection. The manager was able to demonstrate that the home had provided appropriate support following the accident, ensuring that emergency treatment was obtained and that staff monitored the resident closely following her discharge from hospital. The manager advised that arrangements are in place with residents’ placing Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 14 authorities that funding for additional staffing will be made available should hospital admission be required. Residents’ medication is stored and administered using an appropriate monitored dosage system. Inspection of medication records for three residents identified two areas for improvement. The medication removed from one resident’s blister pack for administration did not correspond to the days shown on the blister pack. To avoid the potential for confusion, staff must ensure that they use medication that corresponds to the day of administration. Medication Administration Record sheets contained a number of entries reading ‘F’, which were unexplained by additional notes. Staff must ensure that an explanation is given for all such entries on Medication Administration Record sheets. See Requirements 1 and 2. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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 Appropriate procedures are in place for the management of complaints. Appropriate training and guidance is provided for staff in the recognition, prevention and reporting of abuse. EVIDENCE: The home has an appropriate Complaints procedure. The Regard Partnership provides guidance for staff on handling complaints received and specifies timescales for action and response. The organisation has also developed a Whistle-blowing procedure, which enables staff to report any concerns they have about malpractice. A copy of the Whistle-blowing procedure was in place on both staff files examined. A record of complaints is maintained. No complaints have been made about the service since the last inspection. The home works within the framework of the local authority‘s ‘Joint Policy on Suspected Abuse of Vulnerable Adults’. Employee files provided evidence that staff attended ‘Abuse Awareness’ training in August 2005. Appropriate preemployment checks are carried out on new staff before they start work. (See also Standard 34). Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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, 27, 28, 30 The home is comfortable, safe and well maintained. Communal and private rooms are homely, well decorated and reflect residents’ preferences. EVIDENCE: The home is situated close to the amenities and public transport facilities of Whitton. The property is adjacent to a busy road but noise was not intrusive on the day of inspection. Access to the home is gained to the rear of the property via a quiet residential street. The large garden provides a lawn, patio with seating and carport. Conifers border the garden, giving protection from the noise created by passing traffic. Communal rooms include two lounge areas and a kitchen/dining room. Toilet and bathroom facilities are available on both floors of the home. A good standard of decoration has been achieved throughout the property. Communal rooms were welcoming and homely and private accommodation indicated individual tastes and preferences. All areas of the home were clean and hygienic. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 17 Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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): 31, 32, 33, 34, 35, 36 Staff have an awareness of their own and one another’s’ roles. Staff communicate effectively with one another and have a good awareness of residents’ needs. Staff are appointed following an appropriate recruitment and selection procedure. Staff receive effective induction, supervision and support. 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. Staff communicated well with one another during the inspection and engaged meaningfully with residents. Regular staff meetings and use of systems such as handovers and the Communication book ensure that staff are well briefed on current issues within the home. The service was fully staffed at the time of inspection and a number of staff have worked at the home for some time. As a result, residents are cared for by staff who are known to them and who know their needs. The manager reported that that one member of bank staff had joined the permanent team since the Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 19 last inspection. Staff files provided evidence that staff are recruited according to a robust recruitment procedure and are required to provide proof of identity, appropriate references and Criminal Records Bureau disclosure before they start work. Staff spoken to on the day of inspection confirmed that they receive regular supervision and good support to do their jobs. Staff meetings are held every two weeks. The most recent staff meeting took place on the 6th September 2005. Minutes of the meeting demonstrated that the manager used the forum to address issues including care plans, residents’ reviews, policies and procedures, confidentiality and communication. New starters undertake a programme of induction when they begin work and staff are encouraged to attend training relevant to their roles. The manager advised that the Regard Partnership aims to provide refresher sessions for staff in elements of core training on an annual basis. A number of staff are registered on NVQ (National Vocational Qualification) programmes, although several reported that lack of access to an approved assessor is limiting their progress towards the awards. The Regard Partnership must enable access to an appropriate assessor to ensure that staff have opportunities to complete their awards. See Requirement 3. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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): 37, 38, 40, 42 Systems of recording and administration within the home are clear and well maintained. Staff work within written guidelines and a clear procedural framework. The health and safety of residents and staff within the home is maintained. EVIDENCE: Systems of recording and administration within the home are well organised and maintained. Written information is clear and usable by staff. Staff are issued with a ‘Code of Conduct’ and work within the policies and procedures developed by the organisation. The manager has a number of years experience in her role and clearly knows the home and residents well. The manager is committed to the development of the service and demonstrated a positive approach to the inspection process. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 Page 21 The home was clean, hygienic and free of obvious health and safety hazards on the day of inspection. All COSHH products were stored appropriately. Standards of food storage were satisfactory. The home maintains an Accident book. The property has an appropriate fire detection system. Staff conduct fire and health and safety tests on a regular basis. Clear instructions for use in the event of a fire were displayed. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chertsey Road, 401 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 3 X DS0000017356.V254831.R01.S.doc Version 5.0 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 Standard YA20 Regulation 13(2) Timescale for action Medication administered by staff 15/10/05 must correspond to the day of administration displayed on the blister pack. A written explanation must be 15/10/05 recorded on the Medication Administration Record in all instances where residents have not taken their medication as prescribed. Staff working towards National 30/10/05 Vocational Qualifications must have regular access to an approved assessor. Requirement 2 YA20 13(2) 3 YA32 18(1) 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 YA6 Good Practice Recommendations Ensure that specific goals are identified and recorded at residents’ reviews, including timescales and the person responsible for action. Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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 Chertsey Road, 401 DS0000017356.V254831.R01.S.doc Version 5.0 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. 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