Inspection on 08/06/07 for Douglas Close (19)

This inspection was carried out on 8th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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) 15/07/05

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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Southfields

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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 Douglas Close (19) 19 Douglas Close Jacobswell Guildford Surrey GU4 7RB Lead Inspector Pat Collins Unannounced Inspection 8th June 2007 09:15 Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Douglas Close (19) Address 19 Douglas Close Jacobswell Guildford Surrey GU4 7RB 01483 537181 F/P 01483 537181 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) Mrs Pamela Mary Eales Miss Adrianne Gallagher Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 2 service users may be in the category LD (E), Older people with learning disability The age/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 15th July 2005 Date of last inspection Brief Description of the Service: 19 Douglas Close is a care home registered for provision of personal care for up to three adults with learning disabilities over the age of 45 years, of either gender. The building is an attractive detached bungalow situated in a quiet residential close in Jacobs Well village, Guildford, Surrey. Guildford town centre is a short distance away and has a large range of public services and amenities. The village has a thriving community spirit and the residents of 19 Douglas Close are very much at the heart of it. Bedroom accommodation is all single occupancy. The bedrooms are large and have washing facilities. Communal areas include a large combined lounge/ dining room, fitted kitchen, utility room, bathroom, separate 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. Fees range from £47,129 to £71,822 per annum. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process using the new ‘Inspecting for Better Lives’ (IBL) methodology. Judgements about the home’s conduct and standards of care are based on the cumulative assessment, knowledge and experience of service provision since the time of the last inspection. This inspection incorporates observations during a visit to the home by Ms Pat Collins, Regulation Inspector. The inspection visit commenced at 09:15 hrs and finished at 12:30 hrs and the registered manager was present for most of the time. There are currently two residents living at the home, a man and a woman. When consulted after the inspection visit by a staff member, at the request of the inspector, they expressed their preference to be referred to in this report by the term ‘residents’. The inspection process included discussion with one resident who was at home during the visit. He was very willing to share his experience of life at 19 Douglas Close with the inspector. “I like living here, I have a very nice room” he stated, “ my friends and care manager visit me often. I like the staff and enjoy going out with staff up to London to see the Changing of the Guards. The staff look after me and cook lovely dinners. I’m going on holiday in September to Portsmouth to see the boats”. He was pleased to give the inspector a guided tour of his home with some assistance from a staff member to ensure he did not fall. The privacy of the other resident living at the home that was out at a day centre was respected and her bedroom not entered. Discussions took place with the organisation’s service manager, who is also the home’s registered manager and with the senior support worker on duty. The inspector assessed the home’s performance against all key national minimum standards for younger adults. Records sampled included the statement of purpose and service users guide, complaint and compliments documents, safeguarding vulnerable adults procedures, staff disciplinary and records relating to staff recruitment, induction and training. Additionally a pre-admission assessment for a prospective resident was examined also financial and quality assurance records. The inspection process takes into account information received from the home in a pre-inspection questionnaire. Also comment contained in six questionnaires received from residents, relatives, friends, professionals and a relative of a former resident who sadly died at the home in January this year. The inspector would like to thank all who contributed information during this inspection and the manager for coming in to work on her day off on the day of the inspection visit. What the service does well: Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 6 This home has a sustained record of full compliance with regulations and standards. The outcome of this is a consistently high provision of quality services, support, accommodation and facilities for residents who live at 19 Douglas Close. They are empowered to develop their own individuality, which makes them feel happy and fulfilled. The home is effectively managed and the management style is open and inclusive. Staff are competent and the atmosphere of the home is friendly and welcoming. A professional with regular contact with the home commented “ I have worked indirectly with many care homes over the years and have always been impressed by the professionalism and dedication of the staff at 19 Douglas Close” The home’s operation supports residents in making decisions in their daily lives and they have a strong influence over how their home is run. Staff are very good at promoting individual lifestyles within a safe environment. Both residents are supported in achieving their full potential, giving them the confidence and life-skills that enable independence within individual capabilities. The care planning approach at this home is ‘person centred’ and starts with the individual, not services, taking account of residents’ wishes, needs and aspirations. Innovative ideas support residents’ individual learning. Pictorial information is used to aid communication and residents’ understanding, enabling decision-making. The home has strong links with the local community and residents make good use of community facilities and resources. They have age appropriate programmes of activities based on their individual needs and choices. Residents’ are supported in leading full social lives and in maintaining relationships with friends, family members and other significant people in their lives. A resident stated in a comment card “ I have a lovely life here. I miss living at home sometimes but this is my home too. I have a lot of friends including the Vicar, my neighbours and the shopkeeper”. A regular visitor to the home commented” The care home provides a secure, safe, loving environment for the residents. Staff enable them to join in appropriate local activities and stimulate their interests in life in general. There is awareness of the personal, social, health and spiritual needs of the resident I visit”. Comments from a relative were “ I always find staff friendly and cooperative and they treat my relative with lots of care and kindness”. Staff communicate well with other professionals. Comments from professionals include “ We have excellent communication with the care home who always fully update us on any relevant information” “I am aware the staff have worked particularly well with disabilities and respond to differing faiths”, “Staff treat each person as an individual and offer the best possible care” The complaints and compliments folder contains a number of letters and cards from relatives, professionals, residents’ friends and advocates, complimenting standards of care and the kindness of staff. The home environment is domestic in scale and character, well maintained and attractively decorated and furnished. It is clean and hygienic and the pretty garden is well maintained. Garden furniture is provided and two gazebos afford sunshade. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2,3 & 4 were assessed Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information for prospective residents is available in a suitable format to inform them about the home. A process is in place to ensure that prospective residents’ aspirations and needs are assessed and can be met prior to the offer of a place at the home. Prospective residents have opportunity to ‘test drive’ the home and have real choice in whether they wish to live there. EVIDENCE: The home’s statement of purpose and service user guide has been recently reviewed and updated. The service users guide is in a format that includes symbols, photographs and drawings, making access to this information easier for residents and any potential residents. This document is personalised for each resident and they have been issued with the same. The master statement of purpose and service user guide details additional charges not included in fees. These are hairdressing, chiropody, and membership of the Friendship Club, newspapers, clothing, toilet requisites, leisure activities and private telephone calls. The current residents’ have agreed joint responsibility for charges incurred for veterinary treatment for their pet cat and monthly subscription for satellite television. The home has clear admission criteria in accordance with its stated purpose. A process is in place to ensure that the needs of prospective residents are fully assessed prior to the offer of placements. The current residents have had their Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 10 wishes taken into account when considering referrals for the home’s vacant place. At the time of the inspection visit pre-admission assessment records were viewed for a prospective resident who had been assessed in his own living environment by the manager. The assessment documentation identified areas of need, i.e. disability, mobility, communication, previous lifestyle, cultural background (if any), cognitive impairment, diet, religion, health, personal and social care needs. The assessment process includes collating medical information, care management, nursing needs and physiotherapy assessments and an occupational therapy assessment is to be arranged. Although this individual’s primary needs are learning disabilities, he has secondary physical and health care needs that the home will be capable of meeting within its existing registration, facilities and resources. In discussion with the manager it was clear that admission would not proceed prior to ensuring all necessary equipment was in place. Some equipment is already available at the home, supplied by community health services for the care of a former resident. The manager was planning an increase in staffing levels to ensure safe and appropriate care for all residents following his admission. She was also organising additional staff training in diabetic and catheter care and in moving and handling, in consultation with relevant health professionals. This will ensure staff are competent to fully meet the needs of this individual. A change of vehicle was planned to ensure safe wheelchair access for this individual. The manager had commenced developing a preliminary person centred plan including a social activity plan in advance of the admission. This will be further developed with the prospective resident following admission to ensure his interests, wishes and aspirations are fully addressed. Describing the admission procedures one resident commented “Adrianne (manager) came to visit me and told me all about the home and the people that live here. I came to visit and stayed overnight and we went to the theatre”. The other resident commented, “ I got picture questions and answers (about the home). I visited lots of times for lunch, dinner and outings before making up my mind”. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Person-centred planning fully involves the residents in the review process and in decision making about their lives. Risks involved in living independent life-styles are assessed to balance the positive benefits for residents and protection from harm. EVIDENCE: A care plan was viewed by the inspector and discussed with the resident concerned who clearly took ownership of the same. Residents have allocated key workers and their care plans are reviewed internally with residents at three monthly intervals or more often if necessary. Care management reviews are convened on a regular basis. Residents have a choice of whether to attend reviews. They have opportunity to complete a pictorial quality assurance questionnaire prior to reviews. This is an excellent, holistic tool enabling residents to express opinion about their lives, needs, care and aspirations and this information then used to focus review meetings. The care plan was easy to read and understand, appropriate to the needs of the resident and presented in a person-centred format. This individual’s needs and aspirations are recorded also matters important to this resident, with clear Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 12 information for staff about what they need to do relating to this persons care and support. The home is very good at promoting individual lifestyles within a safe environment. Risk assessments were in place to support activities and needs. Those viewed demonstrated this individual was well supported in making decisions and restricted only when the risk of harm outweighed positive outcomes with his agreement. It was clear from the range of activities which residents engage in that their individual needs are met in a holistic way. Residents are empowered to attain their full potential. “ The staff help me to look nice. I take a bath and they wash my clothes. We have residents meetings and I meet with my key worker fortnightly. If I am worried they let Adrianne (manager) know” commented one resident. The other resident commented “ I like to help myself but I always get help when I need it…staff listen (to me). I have key worker meetings and resident meetings”. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are enabled to live fulfilling lives. They take part in appropriate activities that take account of their needs and preferences. They are supported in maintaining their relationships and to be part of the local community. Residents’ rights and responsibilities are recognised and they are offered a healthy diet that reflects individual tastes and meets dietary needs. EVIDENCE: The initial meeting with the one resident who was home at the time of the inspection visit revealed this individual had good verbal communicate skills and was very confident and happy in the home. “I like it here” stated this resident, “I like the staff, especially that one” pointing to the senior support worker on duty. “We’re going out in a minute to the betting shop and then shopping. I like betting on horses”. The residents each have their own special interests, which they are encouraged and supported in pursuing by staff. Residents are members of social clubs, attend local churches and use leisure facilities both in Guildford and Woking, including libraries, cinema, theatre, bowling, restaurants and shops. “ We were Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 14 treated to fish and chips out last night ” a resident informed the inspector. The senior support worker on duty confirmed she had taken both residents to a local fish and chips restaurant. One of the residents attends local college courses and day centres and was at the day centre on the day of the inspection visit. Comments received from this resident confirmed participation in a wide range of activities outside of the home. Photographs of seaside holidays enjoyed by this individual were displayed .in the home The resident at home stated “I am retired and don’t like going to day centres”. This resident referred to enjoying going to church and was visit by the minister who was regarded by this person as a friend and advocate. “ I like to go out with staff and enjoy watching sport on the television. I have a rest on my bed in the afternoons, I’m eighty eight you know!” This resident invited the inspector to see his bedroom that was personalised, reflecting personal taste and interests. This individual informed the inspector about trips made to London with staff to watch the Changing of the Guards at Buckingham Palace. He maintained scrapbooks with pictures of the Royal Family and had pictures and postcards of Buckingham Palace and various members of the Royal Family displayed on his bedroom wall. He stated he had seen Princess Anne in a car on one of his trips to London. The manager informed the inspector that this resident had a creative talent for story telling and indeed had had a personal account published of when the Queen visited the hospital where he had lived for many years prior to moving into 19 Douglas Close. His other passions included football and he supported the English national football team. He was noted to have a Chelsea football team bedspread on his bed of which he was proud. He supported the National Irish Rugby team informing the inspector of his Irish roots and of his Irish flag bedspread. He stated he enjoyed cricket and watching sport on television; also had an interest in books, purchased magazines and enjoyed war films. This resident is very involved in the local community, being a member of the Jacobs Well Village Association. He attends meetings and is treated as a VIP at events such as Fetes. Staff stated that this resident had preferred not to go on holiday for a number of years because he became home sick. Instead had had lots of days out to places he was interested in. He had been persuaded however to go on holiday this year with a staff member with whom he had a good relationship with. Residents have always assumed responsibilities for domestic tasks that they have chosen. Though one of the residents has decreasing mobility associated with health issues and the ageing process this person still likes to engage in some domestic routines with staff support. One resident is involved in cooking meals and both residents currently keen on baking small cakes. Residents set the dining table and one resident takes an active involvement in keeping the home tidy and enjoyed doing personal laundry. Residents plan menus with staff support on a weekly basis using pictorial aids. They are involved in shopping for food provisions. Special dietary needs were Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 15 being met. A meal was not observed during the visit however the menu demonstrated a varied diet and flexible approach to mealtimes. The dining room was a bright, cheerful and homely and affords congenial surroundings in which to eat. “ I choose what I eat but sometimes I try something different. I don’t like hot curries “ was stated in a comment survey received from one resident. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 and 21 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are met and staff receive relevant training to ensure appropriate delivery of care. The home’s medication policies, procedures and practices ensure medication is safely managed. Ageing, illness and death is managed sensitively and respects residents’ wishes. EVIDENCE: Residents were both registered with a local General Practitioner and comments in surveys received from residents were “ I have a very nice doctor. The staff take me to see him” and “ I have a lovely doctor”. The inspector examined a resident’s health action plan. This clearly stated individual health issues, medical interventions past and planned, and detailed further or on-going action. This person is currently under the care of a specialist health professional. Six monthly health checks are in place and blood pressure and urine analysis for diabetes monitored by the health centre. Records confirmed this individual has access to an oral hygienist, optician, chiropodist and weight was regularly monitored. This resident uses a wheelchair when out and had a new wheelchair. A falls risk assessment has been carried out and a sensor placed under the mat beside this individual’s bed with this person’s agreement as a falls prevention measure. Staff work ‘disturbed night shifts’ as a further precaution. This means staff may sleep part of the night but must also be awake during the night to monitor this person’s Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 17 safety, provide assistance with toileting and respond to the call bell fitted beside this individual’s bed. “I can call staff for help at night” stated this resident whilst demonstrating to the inspector that the call bell worked. Discussion took place with the manager about the complex health needs of a prospective resident. It was noted that pressure risk assessments were to be carried out and other relevant assessments of mobility, health and skin condition; pressure relieving equipment and a suitable bed is to be provided. It was stated that a care plan will be developed for the management of pressure area care fir this individual and staff will receive further training in this area of care. This individual will require a hoist and the home has one on loan that will be used if suitable to meet his needs. A moving and handling risk assessment is to be carried out and staff to receive updated training in this practice. Staff are also to receive training in catheter care. This same individual will be under a diabetic specialist nurse. The manager was organising staff training in practical aspects of caring for this individual’s diabetes. The content of this training was discussed during the inspection. Advice given was for updated training in diabetic care including awareness of specific associated complications of this disorder. Also for the training to include instruction in the safe administration of insulin by subcutaneous injections and disposal of needles; in checking and monitoring blood glucose levels ensuring understanding of the relevance of the outcomes of this test and action to take in response to significant deviation from normal range, also instruction in correct preparation of prescribed dose if not using a pen injection device. The manager was made aware of the need for care staff approved to administer insulin to consent to this and be assessed as competent by the community nurse assuming responsibility for delegating this task. Legal considerations were discussed relating to recording prescribed insulin on medication records with clear written instructions about dose and times of administration. The need to include in the care plan what action is to be taken should this individual have a hypoglycaemic episode and information about the importance of mealtimes and food to be avoided was also discussed. Pre-inspection information received confirmed access to Community Learning Disability Team’s support, to a dietician, occupational therapist and physiotherapist in accordance with individual needs. Medication policies and procedures are regularly reviewed, giving clear instructions to staff. A monitored dosage system is in operation and records maintained of medication received, administered and disposed of. Residents were not self-administering medication at the time of the inspection visit. The medical cupboard was suitable and storage of medication satisfactory. No controlled drugs were prescribed at the time of the visit. The home sadly dealt with the death of a much-loved resident earlier this year. Conversations with the manager, staff member and a resident during the Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 18 inspection visit confirmed this was expected and handled with sensitivity, respecting wishes of this individual and relatives. Feedback received from a relative of this person confirmed satisfaction with the way the staff had managed his terminal care, commenting, “Staff did everything they could to look after my relative”. Observation made of the care documents for an existing resident confirmed this person’s wishes had been sensitively explored concerning illness and death. It is recorded that in the event of this person’s death this individual has written a story and expressed the wish for this to be read out at the funeral. Palliative and end of life care planning and support was briefly discussed with the manager during the course of this inspection. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clear guidance and a good support system encourage residents to express their views. The home’s procedures and policies and well-informed staff protect residents from harm. EVIDENCE: A personal copy of a symbolic complaints procedure, giving clear information to residents about what to do if they were unhappy or wanted to make a complaint has been issued to residents. How to make a complaint is also addressed in personal copies of the home’s service users guide. Monthly residents’ meetings and the key worker support system offer opportunity for residents to make their views known. The complaints and compliments folder contains a number of letters from relatives and other stakeholders thanking staff for their care and attention to current and former residents. No complaints have been received by the Commission of Social Care Inspection about the home from the time of the last inspection. No complaints have been made to the home during the same period. A resident commented in the survey sent to the inspector to questions ‘Do you know how to make a complaint?’ and ‘Do you know who to speak to if unhappy?’ “ Yes, I would tell Adrianne (manager). My visitor always asks me if I am okay. I can tell my care manager or my advocate who visit often”. Comments from the other resident were “ I speak to a relative, the manager and (a named staff member) or (a named person) at Lockwood day centre if unhappy Yes I know how to make a complaint, I will tell Adrianne (manager) or (named staff) ”. An up-to-date copy of Surrey’s multi-agency safeguarding procedures is available in the office. This integrates with the home’s internal safeguarding Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 20 procedures. Minor amendment to the home’s procedure was suggested to the manager to link internal safeguarding procedures, multi-agency procedures and the staff disciplinary procedures. All staff have received safeguarding vulnerable adults training and have access to a whistle blowing procedure. There have been no safeguarding incidents or referrals under the multi-agency safeguarding vulnerable adults procedures since the home’s last inspection. A safe system is in place for the storage and management of residents’ personal money. This supports residents in managing their personal money and in budgeting. Records of all transactions are recorded and receipts kept for expenditure. One resident signs for receipt of personal money and staff countersign their signatures for a resident no longer able to sign for the same. Personal money is held in individual, interest bearing accounts. Systems are in place for staff to check money at the time of shift changeovers and money is securely stored. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable, clean and safe environment, which meets their needs. EVIDENCE: All accommodation is arranged on one level and is domestic in scale and character. There are three large single bedrooms and residents have been issued with keys to their rooms. There is a suitably equipped bathroom and toilet with mobility aids and bath hoist and a separate shower room with toilet and a new shower. Communal rooms are homely, comfortable and tastefully decorated. Framed photographs of residents and resident’s relatives are displayed in the living room. Furnishings are domestic and of good quality. The home is well maintained, in good decorative order, and a programme of redecoration is included in the home’s development plan. The kitchen has been upgraded since the last inspection and there is a separate utility room. Other improvements include new radiator covers and fencing. There is a garden room where guests can be entertained in private and where a Friendship Club takes place. The Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 22 home has two offices facilities. There is an attractive, well-maintained garden with two gazebos and a furnished patio area. The home’s management is responsive to changes in the needs of residents. Over the years various adaptations to the environment have been made and provision of suitable aids and equipment. The home has grab rails fitted throughout, a full- length corridor rail, wall protection covers, a hoist, bed raiser, commode and a detachable raised toilet seat. Ramps are fitted to exits and a call bell fitted beside a bed. The home is clean and hygienic. Currently there is no incontinence and staff are trained in infection control procedures. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34 &35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Safe recruitment practices, which residents contribute to, are in place. Appropriate induction, mandatory and specialist training ensure staff are competent and prepared for their role. EVIDENCE: The home has a very stable staff team all of whom have been in post for many years. Currently some of the staff are deployed in other homes operated by the same organisation until such time as admission of a third resident. All staff have generic roles undertaking care, support and administrative duties in addition to catering, shopping, cleaning and gardening tasks. They encourage and support residents’ involvement in domestic routines within individual levels of capability. From observations of the practise of the senior support worker on duty it was evident that the philosophy of the home was understood and actively followed. Interaction between the staff member, the manager and the resident present at the home was respectful and empowering. Two staff personnel files were inspected. These contained documents confirming statutory recruitment and vetting procedures were followed Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 24 ensuring residents’ safety. Information recorded and discussions with the manager confirmed awareness of equal opportunities legislation and appropriate recruitment practices for compliance. In the past a resident had been involved in the staff recruitment process. The manager stated that all candidates for care posts must meet with residents before a decision can be made. Evidence was seen of induction, foundation, service specific and mandatory training for staff. There is an ongoing National Vocational staff-training programme. The manager was advised to explore staff training opportunities under the Learning Disability Award Framework and to obtain information about the new common induction standards. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well managed and safe home, where their contribution to on-going development is valued. EVIDENCE: The manager is registered by the Commission for Social Care Inspection and is suitable qualified and experienced to manage the home. She has appropriate experience and her qualifications include the Registered Managers Award, NVQ Level 4 in Care and Management and a City and Guilds Diploma in Management. The management structure includes a deputy manager who also has the Registered Managers Award qualification, NVQ level 2 and NVQ Level 4 qualifications and is currently undertaking NVQ Assessors training. The senior team includes a full time and part time senior support worker. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 26 The manager has been promoted within the organisation and in addition to the management of this home is service manager for a group of homes. The manager confirmed she spends three days a week at 19 Douglas Road. A comprehensive quality assurance monitoring system was in place. Monthly visits on behalf of the Responsible Individual were carried out by external managers unannounced and records of these visits were seen in the home. The home has policies and procedures in place for health and safety and also fire safety. All the necessary safety checks have been undertaken and recorded and copies of safety certificates were on file. Staff have received training in health and safety, infection control, control of substances hazardous to health, moving and handling, first aid, fire safety, food hygiene and in safeguarding vulnerable adults procedures. A programme of routine maintenance and records of repairs is evident. Observations identified the certificate of registration displayed was not current. The inspector confirmed she would inform the home’s link inspector in order that arrangements could be made for a current certificate to be sent out. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 4 3 4 4 4 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 4 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 4 4 x 4 x x 3 x Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement 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 YA35 Good Practice Recommendations It is recommended that management explore training for staff under the Learning Disability Award Framework. Also obtains information regarding the new Common Induction Standards. Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Douglas Close (19) DS0000013457.V335290.R01.S.doc Version 5.2 Page 30 - 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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