Inspection on 04/05/05 for Coveham

This inspection was carried out on 4th May 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

Coveham 25/06/07

Coveham 06/12/05

Coveham 11/11/04

Coveham 02/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Coveham Annyards Road Cobham Surrey KT21 2LJ Lead Inspector Mr P Benthom Announced Inspection 04 May 2005 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 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 Stationary 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. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Coveham Address Annyards Road, Cobham, Surrey. KT21 2LJ 01932 864115 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Surrey County Council - Adults & Community Care To be confirmed CRH (PC) 20 Category(ies) of Learning disability (LD) 20. registration, with number of places Learning disability over 65 years of age (LD(E)) 1. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Accommodation and services may be provided to named persons aged 65 years and over with prior written agreement of the CSCI. The matters detailed in the attached schedule of requirements, must be completed within the stated time scales. Date of last inspection 11 November 2004 Brief Description of the Service: Coveham is a purpose built local authority home providing accommodation for twenty service users. The home is located in a residential road in Cobham and has easy access to shops, public transport and other local services. On the day of inspection there were seven service users currently at home. The accommodation for service users is provided on two floors. All bedrooms are single. In addition to this there are two self-contained flats linked to the main building where service users are afforded a supported living environment. The communal space provided comprises of a bright and comfortably furnished lounges, dining rooms, well fitted kitchens, a communal laundry and suitable bathroom/toilet facilities. There is a large garden at the rear and a good-sized lawn area in the front. The are parking facilities in the front drive for up to ten cars. The home has its own vehicle for use by its service users. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the first of the year 2005/6 and was conducted by an inspector from CSCI. The manager has been in post since February 2005 and was present for the inspection. The deputy manager was also present for the inspection. Three members of staff were on duty in one unit of ten Service Users and one member of staff in the remaining units where up to three Service Users were accommodated. One Service User has 1 to 1 support. Eight of the Service Users were spoken with; the parents of a Service Users chose to meet with the inspector during the course of the inspection. A tour of the premises took place and care, training and Health and Safety records were inspected. The home provided a high level of support to service users. What the service does well: The home provides adequate information to service users regarding the aims, objectives and facilities available at the service. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 6 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. Each service user has a clearly set out care plan and all the service users are registered with a GP. There were satisfactory facilities and procedures available for the safe reception, storage, disposal, administration and recording of medication. Arrangements are in place to meet service users care needs in a respectful way that affords both privacy and dignity. Staff are committed to encouraging service users to take part in activities offered in the home. Full support is provided to enable individual choice in daily living activities. Care plans have been drawn up, with the help of the service users’ families/representatives and other professional outside agencies who are familiar with the service users. The individual care plans were well documented and covered areas of care needs for each service user. A range of activities is in place for the service users to participate in. Service users are encouraged to visit their families and staff will offer support. Some good relationships between staff and service users’ families were evidenced. Service users have regular outings and they go on excursions and holidays. What has improved since the last inspection? What they could do better: The manager must submit an application for registration as soon as possible in order to ensure that professional standards within the home can be maintained and the home complies with the legislation. The Statement of Purpose needs to state that respite care or emergency admissions are not part of the home’s operation. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 7 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. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 9 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 standard(s) 1, 2, 3, 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The management team were able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The statement of purpose was professionally produced and was considered comprehensive and contained all the relevant information required by schedule 1 of the Care Homes Regulations 2001. The manager is competent to carry out full assessments on service users prior to admission. Relatives and/or representatives are involved in this process when service users have problems expressing themselves. Observation and discussion with staff members and an inspection of records indicated that the home had the capacity to meet the service users’ assessed needs. The registered manager stated that unplanned admission to the home is avoided and emergency placement would not be considered. Within the current Statement of Purpose and Service Users’ guide this was not stated. It is required therefore that this is made clear in the Statement of Purpose. Please see requirements. There is a written statement of terms and conditions between the home and each service user Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 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 standard(s) 6, 7, 8, 9 and 10 The systems for Service User consultation are good with a variety of evidence that indicates Service Users views are both sought and acted upon. EVIDENCE: Each service user has a care plan in place, which is detailed and covers the assessed needs of the service user. Care plans reflect multidisciplinary input. One care plan was examined in relation to one Service User being afforded the opportunity to live independently in the community, and it contained guidelines for staff about support that needs to be provided for the individuals’ eventual discharge. Staff were seen to be supportive of service users making their own decisions. It was evident that the needs of individual Service Users were identified and an action plan put in place to meet their needs. There was evidence of reviews being carried out by the key workers and of the action taken as a result of the review. Staff stated that the staff team are committed to encouraging Service Users to lead their lives independently. It is common practice at Coveham to involve Service Users in a number of daily activities within the home. There are regular Service Users meetings held and they are given the opportunity to express their views. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 11 There was evidence that risk assessments were routinely carried out on each of the service users on a regular basis. Members of staff are aware of potential risk for individual service users and adhere to the risk management strategy in place for that individual. Staff are aware of the need for confidentiality and are aware that information about service users is confidential. They are aware of the home’s policy, which is clear and concise. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 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 standard(s) 12, 13, 14, 15, 16 and 17 Links with the local community are good and serve to enrich Service Users lives. EVIDENCE: A meaningful fulfilling daily activity programme for each Service User was seen as part of the inspection process. Service users make use of the local facilities and go out to pubs and restaurants. Supported by members of staff they go shopping for their toiletries, clothing and footwear. All outings are subject to risk-assessments. A Service Users parents were spoken with during the course of the inspection and they emphasised how involved they were in the day to day life of the home and that the Friends of Coveham encourages them to participate in some of the home’s regular activities. The management stated that the home maintains close relationships with service users’ families. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 13 Service users were given unrestricted access to the home subject to their individual risk-assessments and the inspector saw individuals using different parts of the home. During the inspection, service users enjoyed a well-balanced and nutritious lunch. Staff were seen to be supporting service users, lunchtime was observed to be enjoyed in a relaxed, unhurried manner in a pleasant dining area. A copy of the menu was seen as part of the inspection process and personal preferences were taken into account. The kitchens on the units were clean and tidy and relevant health and safety notices were noted e.g. regarding routine testing of the refrigerator temperatures. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 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 standard(s) 18, 19, 20 and 21 The healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: The home had adopted a key worker system and each individual service user had a key worker who knew them and their family well. The key worker with support from the management team was responsible for developing and reviewing the service users’ care plan. Staff ensured that specialist support was provided where necessary. All service users are registered with the local GP. A local surgery provides health care to the service users, which includes health checks, continent assessment and some staff training. The arrangements for all aspects of administration of medication appeared to be satisfactory. No service users had the capacity to manage any aspect of their medication. Medicines for each service user were recorded and stored accordingly in line with the RPS (Royal Pharmaceutical Society) guidelines. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 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 standard(s) 22 and 23 Service Users are well protected by the Surrey County Council’s training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: A copy of the home’s complaints procedure was seen and appeared to met the necessary standard. There had been no complaints since the last inspection. Members of staff spoken to at the day of the inspection had a good and clear understanding of the Whistle Blowing Policy. Surrey County Council has a complaints procedure and Service Users are also able to use an independent advocacy agency. User-friendly complaints forms are available for Service Users. Up to date training in the Protection of Vulnerable Adults is in place. The last training took place in April 2005. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The standard of the environment within this home is good providing Service Users with an attractive and homely place to live. EVIDENCE: Overall the home was in good condition; appropriately decorated, well maintained and furnished to a high standard. The secluded garden is particularly attractive and of a large size, stocked with garden furniture. Some bedrooms were seen during the inspection. These were each highly personalised and individual in style. Most of the bedrooms had photographs and other items linked to the Service Users family life outside the home. There were sufficient bathrooms and toilets to meet the national minimum standard. The communal areas in the home were considered safe and accessible for the Service Users. There was a good size separate room available for the service users to use and if required to use as a family visiting room. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. At the day of the inspection personnel files were seen and considered to be accurate. All documents required by Schedule 2 of the Care Homes Regulations 2001 were available in individual files. Staff meetings are in place and are organised monthly. Staff meeting-minutes were seen as part of the inspection process. The manager gave evidence of a professional and comprehensive induction period for new members of staff. Staff confirmed that they receive training on a regular basis. All members of staff receive supervision on a regular basis. The deputy manager of the home carries some supervision responsibilities and the manager provides supervision to the deputy manager. 60 of staff have completed or are undertaking NVQ training. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 and 43 The manager has a clear development plan and vision for the home, which she has effectively communicated to the Service Users, staff and relatives. EVIDENCE: The manager and the deputy manager are highly experienced in their profession and both have worked for the organisation for a number of years. The manager is NVQ Level 4 qualified and has had extensive relevant experience. She is employed full time working supernumerary to staffing levels. Relevant policies and procedures were in place. Systems existed to demonstrate these had been communicated to staff. Also those of relevance to Service Users had been shared with them. Records examined included; care plans, medication procedures, and staff meeting minutes, risk assessment policies and service user activity programmes. They were observed to be in good order. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 19 Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 20 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 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coveham Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 21 no 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 YA37 Regulation 8(1)a) Requirement It is required that the managers application for registration is forwarded to CSCI as soon as possible. Timescale for action 31/5/05 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 Good Practice Recommendations There are to be no recommendations from this inspection. Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 Coveham H58 H09 s34623 Coveham v216359 040505 Stage 4 ann.doc Version 1.30 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!