Inspection on 07/11/05 for Cobham Road (60)

This inspection was carried out on 7th November 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cobham Road (60) 17/08/06

Cobham Road (60) 14/07/05

Cobham Road (60) 17/11/04

Cobham Road (60) 06/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Cobham Road (60) 60 Cobham Road Fetcham Surrey KT22 9SS Lead Inspector Deavanand Ramdas Unannounced Inspection 7th November 2005 09:30 Cobham Road (60) DS0000013894.V264512.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.org.uk Internet address Cobham Road (60) DS0000013894.V264512.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, 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. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cobham Road (60) Address 60 Cobham Road Fetcham Surrey KT22 9SS 01372 379623 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) Milbury Care Services Limited Mrs Rosalind Herty Mensah Dodd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 30-60 YEARS OF AGE 14th July 2005 Date of last inspection Brief Description of the Service: Cobham Road (60) is a care home for six service users with learning disabilities. The home has a vacancy for one service user. The property is located in a residential area in Fetcham, Surrey and is within walking distance of the town centre. Epsom, Guildford and Leatherhead shopping centres are nearby and can be accessed using public transport. The property has a private drive and parking is available. There is a well maintained garden to the back of the property that is private and secure. Accommodation is on two floors which can be accessed by stairs. There are six single bedrooms. The facilities on offer include an office, a large communal area, a dining room, a kitchen, bathing and washing facilities and a laundry. The registered provider is Milbury Care Services Limited and the Registered Manager is Rosalind Dodd. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of six hours. A partial tour of the premises took place, staff and service users were spoken to and documents and records examined. The service users living at the home have communication difficulties and the inspector made judgements about them based upon their mood and behaviour. The inspector would like to thank the manager, staff and service users for their contributions during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure the flooring in the toilet, kitchen and bathroom is replaced to make the environment nice and hygienic for service users. The training needs of staff must be reviewed and bereavement training should be considered to ensure staffs have appropriate knowledge and skills to handle ageing, illness and death of a service user. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cobham Road (60) DS0000013894.V264512.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 Cobham Road (60) DS0000013894.V264512.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): 1,3&4. The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for assessing service users needs are adequate ensuring service users needs and aspirations are identified and met. The admissions policy is good ensuring prospective service users have the opportunity to visit and ‘test drive’ the home. EVIDENCE: The home had a Statement of Purpose and Service User Guide that was reviewed and updated in 2005. The Statement of Purpose contained information about the aims, objectives and philosophy of the home. The inspector noted the Statement of Purpose was kept in the office and available to staff, service users and relatives. The home has an admissions procedure dated 01.05.05. The manager stated the home would not offer a place to someone whose needs it cannot meet. The inspector noted the home had one vacancy for a service user. The manager stated the home has three staffs that have the NVQ qualification and remarked four staffs are working towards the qualification. During a meeting two staffs stated they had the NVQ qualification. The inspector noted staff used verbal prompts and gestures to support service users. The manager stated any prospective service user would be offered a trail visit to the home and remarked prospective service users, families and friends would be encouraged to visit and assess the suitability of Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 9 the home. The inspector noted this was reflected in the admissions procedure of the home. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8&10 The arrangements at the home for participation are satisfactory ensuring service users are consulted in all aspects of life in the home. The systems at the home for handling information are adequate ensuring information on service users is stored confidentially. EVIDENCE: The home has a policy on participation that was dated 01.05.05. The manager stated the home had regular meetings with service users. The inspector sampled the minutes of meetings and noted the last meeting was held on the 31.08.05 and attended by three staffs and five service users. It was recorded in the minutes service users discussed their annual holidays and key workers. The inspector noted three service users went to Blackpool on holiday from the 17.10.05 to 22.10.05 travelling by coach and train. The manager stated it was the first time in four years service users had travelled by public transport to go on holiday. During a meeting staff remarked this was a great achievement by the service users and commented they had a very nice holiday. The home had a policy on confidentiality that was dated 01.05.05. The inspector sampled service users care plans and finance records that were up to date and accurate. The inspector noted sensitive information on service users were kept Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 11 in a locked cabinet in the office. During the inspection one staff updated the finance records of service users who had returned from shopping in the community. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15&17. The arrangements at the home ensure service users are able to take part in activities with their peers. The arrangements for support are satisfactory ensuring service users maintain family links. The meals in this home are satisfactory offering both variety and choice. EVIDENCE: The home had a policy on community links and social inclusion that was dated 01.05.05. On the day of the inspection the inspector noted two service users had attended the Cheam Centre supported by staff. The inspector sampled the activity log and noted one service user had a cookery session and the other an art group. The manager stated service users had the opportunity to meet with their peers at the Cheam Centre. The inspector sampled service users finance records and noted staff supported service users to go to the local bank and make withdrawals from their accounts. The manager remarked this activity gives service users the opportunity to learn about handling money. The home had a policy on sexuality that was dated 01.05.05. The manager stated service users at the home did not have personal intimate relationships with others. The manager commented the home encourages and supports service users to maintain relationships with family and friends. The inspector sampled the activity log and noted staff supported a service user to visit his mother at Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 13 home on the 26.10.05 using the homes transport. The manager stated the home had a weekly planned menu that was sampled. The inspector noted the meals on the menu were varied and offered choice. On the day of the inspection service users had a lunch of meatballs with boiled potatoes and mixed vegetables. Dessert was a choice of rice pudding or fresh fruits and orange juice and other drinks were readily available during lunch. The inspector noted diet guidelines were in place for one service user who had a high cholesterol problem. Mealtimes were relaxed and unhurried and staff supported service users using verbal prompts. The inspector noted service users moved freely between the dining room and the kitchen and helped in clearing the dining table after lunch. The inspector noted service users were smiling during lunch and ate all of their meals. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20&21 The arrangements for managing medications are satisfactory ensuring the promotion of good health. The arrangements for managing illness and death are adequate ensuring the illness and death of a service user is handled as they would wish. EVIDENCE: The home had a policy on safety and issue of medications dated 01.05.05. The inspector noted medications were stored in a locked metal cupboard secured to the wall in the office. The inspector sampled staff training records and noted staff were assessed as competent in administering medications. The inspector noted a nurse had assessed one staff as competent to administer rectal diazepam that was signed and dated 02.04.04. The inspector sampled monthly medication records and noted medications were received at the home on the 12.10.05 that was checked by the deputy manager and countersigned by the manager. The home had a disposal of medicine form and an entry was made on 06. 09. 05 that was signed by the pharmacist. The inspector sampled medications recording sheets and noted they had a photograph of the service user attached. Medications recording sheets were signed and dated by staff. The home had an audit on the 06.09.05 that was carried out by the local pharmacist and no recommendations were made following the audit. The home had a policy on death of a service user dated 01.05.05. The inspector noted the home had made arrangements with service users and their families Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 15 about what action is to be taken in the event of death of a service user. It was recorded the wish of a relative is for her son to be buried in the family grave in Epsom cemetery. The manager stated she attended a training course on ‘Let’s Talk about Death’ and had a booklet about death and funerals for people with a learning disability that was available in the home for information. The inspector noted bereavement training was not available to staff. This was discussed with the manager and action has been required in respect of this matter. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaints process in this home is satisfactory with complaints information available to staff and relatives. EVIDENCE: The home had a complaint policy that was dated 01.05.05 and kept in the policies and procedures file in the manager’s office. The manager stated the home had a complaint folder that was sampled. The inspector noted there had been one anonymous complaint since the last inspection that was dated 27.07.05 and management action had been taken. The complaint section in the statement of purpose had been updated and information on complaints was available in the home. During a meeting staff remarked they were aware of the complaints procedure. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 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 The standard of the environment within this home is satisfactory however the flooring in some areas of the home must be replaced for health and safety reasons. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from mal odour. The furnishings and fittings were satisfactory and the standard of décor was good. The garden was well maintained. During the inspection it was noted service users had free access to all parts of the home. One service user was listening to music in the conservatory and another was in the dining room doing a jigsaw puzzle with a member of staff. The home is in keeping with the local community and is located in a residential area within walking distance of the local shops and other amenities. The inspector noted a requirement to replace the flooring in the kitchen, bathroom and toilet areas in order to improve the environment had not been carried out. This was discussed with the manager and action has been required in respect of this matter. Cobham Road (60) DS0000013894.V264512.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&35 The management system at the home ensures staffs understand their roles and responsibilities to the benefit of service users. The arrangements for staff training are adequate ensuring service users needs are met by appropriately trained staff. EVIDENCE: The home has a staff management structure with the registered manager and deputy manager leading and directing the staff team. The manager stated she delegated responsibilities to staff based on their competence. The inspector noted the deputy manager had completed a training course in disciplinary and appraisal and was involved in appraising and supervising staff. One support worker had health and safety training in risk assessment dated 03.11.04 and took the lead in the home on health and safety. During a meeting staff stated they were aware of the philosophy of the home and understood the policies and procedures. The inspector noted the home operated a key worker system. The manager stated the home had structured induction training. The inspector sampled training files and noted staff doing the learning disability award framework accredited training. One staff had completed two units and had a certificate that was in her file. The inspector noted another staff had received epilepsy awareness training dated 02.04.04 that is linked to a service user who has a diagnosis of epilepsy. During a meeting the manager remarked the company was committed to training and development and provided a good training programme for staff. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 19 Cobham Road (60) DS0000013894.V264512.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): 39,41,42 &43. The home regularly reviews aspects of its performance through a programme of self-review and consultations with service users, relatives, staff and other stakeholders. The systems at the home for record keeping are satisfactory ensuring service users rights are safeguarded. The arrangements for health and safety are adequate ensuring the welfare of service users are protected. The arrangements for the management of the home are satisfactory ensuring the interests of service users are protected. EVIDENCE: The home had a policy on quality assurance that was dated 01.05.05. The manager stated as part of quality monitoring the home had an annual service review on the 13.10.05 to which staff, service users, relatives and other stakeholders were invited. The inspector noted the Commission had received an invitation to attend the review. The manager remarked the results of the annual review would be made available in the form of a report for information. The inspector noted one of the requirements identified in the previous inspection report was not met and is referred to on page 17 of this report. The manager stated records at the home are secure. The inspector noted the home Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 21 had three lockable cabinets in the office to store records. The inspector sampled policies and procedures and noted they had been reviewed and updated in 2005. The home had a health and safety folder that contained policies on infection control, incident reporting, food hygiene, first aid and risk assessments. The inspector sampled records and noted the home had an extinguisher service certificate dated 21.09.05, a gas safety record dated 22.01.05, a legionella risk assessment dated September 2005 and a PAT test certificate dated 19.07.05. Food temperatures and water temperatures were sampled and found to be within normal limits. The inspector noted the last weekly fire audit check was completed on 06.11.05. The company has a business plan and the home has an annual budget. The manager stated she had responsibility for the homes budget and reports to the operational manager to ensure the budget is viable. The home had a certificate of employer liability insurance due to expire on the 31.03.06. Cobham Road (60) DS0000013894.V264512.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 3 X 3 3 X Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cobham Road (60) Score x x 3 3 Standard No 37 38 39 40 41 42 43 Score x x 3 X 3 3 3 DS0000013894.V264512.R01.S.doc Version 5.0 Page 23 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 4(a)(c) Requirement The registered person must ensure the floor covering in the toilet, bathroom and kitchen is replaced to prevent the spread of infection and ensure safe working practice. The previous timescale of 01/11/05 was not met. Timescale for action 01/03/06 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 YA40 Good Practice Recommendations The registered person shall consider bereavement training to be made available to the staff team. Cobham Road (60) DS0000013894.V264512.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Cobham Road (60) DS0000013894.V264512.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. 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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