Inspection on 15/07/05 for Douglas Close (19)

This inspection was carried out on 15th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Douglas Close (19) 02/06/09

Douglas Close (19) 08/06/07

Douglas Close (19) 26/04/05

Douglas Close (19) 06/10/04

Douglas Close (19) 21/07/04

Douglas Close (19) 04/03/04

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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 19 Douglas Close Jacobswell Guildford Surrey GU4 7RB Lead Inspector Chris Bowman Unannounced 15 July 2005, 16:00 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. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 19 Douglas Close Address Jacobswell, Guildford, Surrey GU4 7RB 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) 01483 537181 Mrs Pamela Mary Eales Miss Adrianne Gallagher Care Home 3 Category(ies) of LD Learning Disabilities - 3LD(E) Learning registration, with number Disabilities over 65 - 2 of places 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The Age range of the persons to be accommodated will be 45-65 years of age, up to 2 (two) being over 65 years of age. 2 Up to 2 service users may be category LD(E), Older people with learning disability. Date of last inspection 26 April 2005 Brief Description of the Service: 19 Douglas Close is an attractive detached bungalow in a quiet close in Jacobs Well village. Although very close to Guildford with its large range of public services and amenities, this village has a thriving community spirit and the residents of 19 Douglas Close are at the heart of it. This home has three large bedrooms for the residents and attractive communal spaces, including a large sitting/dining room, a kitchen, a utility room, bathroom, shower room, and an activity/visitors room in the garden. There is a terraced area in the garden for eating out in the summer, and parking spaces in the drive and on the road. The placements at this home are for three people with learning disabilities who are over the age of forty five years. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It was the second of two for the year beginning April 2005 to March 2006 and took place over three and a half hours. Two members of staff were interviewed and the three residents were at home and happy to talk about the many and varied activities they had been involved in since the last inspection. Records, policies and staff and residents files were viewed and a meal was taken with the residents. The atmosphere was relaxed and the residents were happy and well cared for. What the service does well: What has improved since the last inspection? The radiator covers, which had been ordered before the last inspection, were in place. A new washing machine and dryer had been purchased as planned and were in place and a new shower had been installed. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 6 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. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 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 standard(s) 2 and 3 Comprehensive assessments had been completed and were available on resident’s files. The home matched those assessed needs ensuring the satisfaction of residents. EVIDENCE: The assessed care needs of residents corresponded to the care speciality of the home in the Statement of Purpose and the Service User’s Guide. All required areas of need were covered and information transferred to the care plan. Preferred modes of communication were noted and observations were made of the use of Makaton and pictorial cards to assist in the making of choices. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 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 standard(s) 6,7 and 8 Residents had been involved in the reviewing of their care plans, either by attending the meeting and taking an active part or completing a pictorial questionnaire prior to the meeting. Residents are supported to make decisions about their own lives leading to more independence. Residents are consulted on and participate in, all aspects of life in the home, which increases confidence and self-esteem. EVIDENCE: All residents make a choice about whether or not they wish to attend their review meetings a member of staff stated. They are involved in reviewing their care plans either by attending the meeting and taking an active part or by completing a pictorial questionnaire about their home with their key worker, which informs the participants of the resident’s views. Care plan objectives are reviewed every six months and this was clearly seen in the resident’s files. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 10 A daily log of choices made by the residents themselves was kept. It included such choices as; the resident chose to buy a coat with their birthday money, the resident chose a meal from the menu when eating out, the resident chose to have a glass of sherry at the Social Club, the resident chose to participate in the resident’s meeting and the resident chose to ask a prospective member of staff questions at their interview. Throughout the inspection residents were consulted about many things including, helping to prepare for tea, what they would like to drink, a resident whose mobility has deteriorated was asked where he would like to sit when he was supported into the living room. The residents were consulted about eating out on the terrace. One resident chose to eat inside, so a member of staff stayed with the resident throughout the meal whilst the others ate outside. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 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 standard(s) 13,14 and 17 Residents choose their lifestyles and are very individual in their taste. They choose to be involved in the local community and are enthusiastic about engaging in the many leisure activities available locally. EVIDENCE: All residents have a schedule of community presence in their care plans, which they choose. One residents schedule included attending the ‘Over 60’s Club’ from 9.00am to 4.00pm on Monday, Wednesday and Friday, attending a ‘Music and Mime Class’ on Tuesday afternoon and Friendship Club on Thursday. There was still time to spend an evening with a relative, go shopping, go to the pub, attend a social club one evening and enjoy an evening at home. Weekend activities were varied and included, going to Woking market, going to the library, planned outings, videos at home and church on Sunday. One resident was keen to talk about the fact that he had been playing skittles the day before and he had won. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 12 There had been two birthday celebrations recently, a member of staff stated. The staff had arranged for a double birthday party and friends were invited. A resident who is interested in anything connected with the war, chose to have some military music and had a march through the house. There had been a trip to the military air show at Aldershot and he had been in a helicopter as part of his birthday treat. He had bought himself a soldier, which sings, ’We will rock you,’ and he had also been to the cinema to see, ‘The War of the Warriors’. There had also been a boat trip down the Thames and the resident who is a big fan of the Royal Family was hoping for a glimpse of Windsor Castle. Unfortunately the boat trip didn’t pass the castle so they stopped for a snack and approached it by road. A resident, who likes to try new experiences, was talking about her intention to go on a holiday, where she could go on an aeroplane. She had already obtained a passport and was planning the trip with a friend from one of the other ‘Just Homes’ homes. She was thinking about maybe going to Jersey or to Spain. Menus were inspected. The weekly menu is selected from four choices for each meal and this is done together on Sundays a member of staff said. The menu showed a good variety of well balanced, nutritious and healthy meals to choose from. For those with communication difficulties there were picture cards showing the complete meal on a plate to assist with choosing. A record is kept of the meals taken. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 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 standard(s) 20 Risk assessments were in place and preclude residents from controlling their own medication, as it would not be safe for them to do so. The home had very clear policies and procedures for the handling and administration of medicines, which protect residents. EVIDENCE: Each resident had a clear medical profile with photograph and consent of the resident to medication recorded. There was evidence of training in the administration of medicine by a pharmacist and the medicines were blister packed. MAR sheets were accurately recorded and signed and there were no occasions when medication had been missed or not signed for. Policies and procedures were clear and the metal cabinet in which the drugs were contained was locked. There was a receipt book for medication returned to the pharmacy. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 14 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 Residents meetings, key worker support and the respectful and caring ethos of the home promote confidence in the residents to air their views, know they will be listened to and that their views will be taken seriously. Training in the protection of vulnerable adults informs the staff of how to guard against situations, which could be harmful to residents and how to respond if a situation should occur. EVIDENCE: The complaints procedure was readily available and there were many opportunities for residents to make their views known. Records were kept of resident’s meetings, of key worker meetings and logs were kept of residents’ day-to-day communications. The staff had become proficient in the use of Makaton in order to communicate with the resident who had communication difficulties. No complaints had been received by the home. The staff had recently been updated in the protection of vulnerable adults training. This was evidenced in staff files. Resident’s personal finances were inspected. A clear account of cash received and spent was kept. Receipt numbers were recorded as were items purchased and each transaction was signed and dated. Balances were correct. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 15 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 and 30 19 Douglas Close offers its residents a comfortable, homely, safe, clean and hygienic environment in which to live. EVIDENCE: This home is situated in a quiet close and is in keeping with the local community. There have been adaptations to provide access to wheelchair users. The home has a programme of planned maintenance, renewal and redecoration. Radiator covers have been installed since the last inspection and the kitchen is due to be updated in the near future. A new washing machine and dryer have been purchased. A new shower had been installed in the shower room. The premises are bright, clean and cheerful and meet the needs of the residents in a comfortable and homely way. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 16 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) 33 Residents receive care from an establish team of well-trained staff who know them well. EVIDENCE: There had been no changes of staff since the last inspection and training had taken place as planned. Observations made on the day were of staff engaging residents in positive and empowering relationships. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 17 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) 39 and 42 Residents are fully involved in the running of the home and know that their views are taken seriously. Safe working practises protect the residents. EVIDENCE: This home has a system of self-monitoring and the residents complete quality assurance surveys, which feed into the review and development of the home. The staff on duty showed a good understanding of food hygiene and fridge and freezer temperatures were routinely recorded. All food was dated when opened or stored and food temperatures were also routinely recorded. The boiler had been recently serviced and there were no health or safety issues. 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 4 4 x x 4 Standard No 31 32 33 34 35 36 Score x x 4 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 19 Douglas Close Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 19 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 Regulation Requirement There were no requirements. Timescale for action 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 19 Douglas Close H58 H09 s13457 Douglas Close v240197 150705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill 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. 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