Inspection on 16/06/05 for East Surrey Carer`s Support Services

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

East Surrey Carer`s Support... 07/12/06

East Surrey Carer`s Support... 22/09/05

Similar services:

Southfields

Thorndene

Insight - Eastchurch

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 5 Gloucester Road 5 Gloucester Road, Redhill, Surrey, RH1 1BP Lead Inspector Kerry Fell Unannounced 16 June 2005 10:20 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. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 5 Gloucester Road Address 5 Gloucester Road, Redhill, Surrey, RH1 1BP 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) 01737 765800 Prospect Housing Association Limited to be confirmed CRH Care Home 5 Category(ies) of LD Learning disability, 5 registration, with number MD Mental Disorder, 3 of places 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the five (5) residents accommodated, up to three residents may fall within the category MD. 2 The age/age range of the persons to be accommodated will be: 54 - 65 years. 3 Accommodation and services may be provided to a named person aged 65 years, with the prior written agreement of the C.S.C.I. Date of last inspection 6th October 2004 Brief Description of the Service: 5 Gloucester Road is a care home that can provide a service to younger adults between the ages of 54 and 65 years, with a learning disability. Up to three placements can be for younger adults with a mental illness. The home is owned and managed by Prospect Housing Association, and is situated close to Redhill town centre with easy access to public transport. The home is a detached town house, with a communal lounge, dining area, large kitchen, one bedroom and shower room on the ground floor. A second shower room is available on a mezzanine floor between the ground and first floor. The remaining four bedrooms are on the first floor with a bath room. All bedroom doors have locks and are furnished to meet service users needs. Laundry facilities and offices are on the second floor. Limited car parking is available to the front of the house, with additional parking available at pay and display car parks nearby. A large enclosed garden is available to the rear of the home. At the time of the Inspection the home had one vacancy. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the inspection year 2005/2006. This was an unannounced inspection, which means that neither the staff nor the service users knew that the inspection was going to take place. The inspection was undertaken by Mrs Kerry Fell, commenced at 10.20 and took four hours to complete. At the time of the inspection the home had one vacancy. Two service users were met during the inspection. The inspector also looked at staff files, service user records, the home environment, complaint records, the statement of purpose and service user guide. The service users residing at 5 Gloucester Road have learning disabilities and/or mental illness, in this case it meant that although communication was possible between the inspector and service users, it was not always possible for the inspector to gain a clear response to questions concerning the home. Therefore, much of the evidence included in this report is based on observations made during the inspection, interviews with members of staff and the sampling of records. What the service does well: What has improved since the last inspection? What they could do better: Areas of the home are beginning to look tired, and the home must consider how this will be tackled when completing the service development plan. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 6 Although it is recognised that the Acting Manager is reviewing records – the completion of the statement of purpose, service user guide and risk assessments must be made a priority. The Acting Manager must also register with the CSCI without delay. 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. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 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 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 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) 1 and 2 The statement of purpose and service user’s guide require updating. This has been identified by the Acting Manager and should be made a priority. EVIDENCE: A statement of purpose is available in the home, and elements had been updated to reflect the appointment of the new Acting Manager. The Acting Manager stated that they recognised that this document needed reviewing and was in the process of completing this. Observations of how the service users communicated and conversations with staff and the Acting Manager demonstrated that this document is not in a service user format. The Acting Manager stated that they were in the process of arranging for a photo document to be developed. The Inspector observed that a service user guide was available in the hallway. This document needed updating. There were elements that were in symbols but again the Acting Manager confirmed that it was under review. The completion of this must be made a priority. The home continues to have one vacancy, but have received no referrals. All other service users have been resident at the home since it was opened, and were placed in the home directly from long stay hospitals. Pre-admission 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 9 assessments was not observed on service users files, therefore copies of these must be obtained where possible. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.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 and 9. Service users were supported to participate in their lives by the clear up to date care plans and the risk assessments available. EVIDENCE: Care plans observed during the inspection had recently been reviewed, and were signed and dated. The detail and format of these care plans were clear and thorough. This was reflected by the observations made during the Inspection, and it was evident that staff understood the needs of the service users, and how to support them. Staff advised the Inspector that these care plans were reviewed with the service user, and that the service user would agree the plan where possible. Evidence was observed throughout the inspection of examples of when service users were supported to make decisions about their daily lives, and service users were observed choosing where they wished to spend their time, and when they wanted drinks. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 11 The home has introduced a staff photo board, and the Inspector was advised that staff are in the process of developing other photo documents including a photo menu, which will assist the service users to choose their weekly menu. The Inspector was advised that the home were still awaiting a response from the advocacy service. Minutes of service users meetings were observed. Staff and service users spoke about activities that took place, for example going out personal shopping, and assisting in cleaning the house and completing laundry tasks. Some risk assessments had been completed for service users, mainly in relation to activities or events that would cause anxiety or risk. Most of those risk assessments observed during the inspection had been reviewed. The review of the risk assessments must be completed. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.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) 12,13,15,16 and 17 Service users are supported to maintain their independence and relationships through a range of activities and daily routines, and by the home developing a photographic menu. EVIDENCE: Two service users were working at a local workshop during the inspection, and one service user talked about a gardening session that they were to attend the day after the inspection. The Inspector observed from care plans that service users have an activity timetable, which included accessing sessions at local daycentres. Staff advised the Inspector that the service users have choice over what activities they take part in. Staff stated that service users are given the opportunity to attend church on Sundays. Staff also talked about planned holidays for the service users. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 13 “Circle of Friends” charts were held for service users that detailed people who are important to them. Members of staff talked about how they supported the service users to maintain relationships with their relatives where appropriate. One service user talked about the people that visited them. Members of staff spoken to during the Inspection stated that the change in staffing levels occasionally affected the activities that service users took part in on weekends and evenings. The home must ensure that service users lifestyles are not affected by staffing levels. Service users can hold keys to their bedrooms, although this was not observed during the inspection. Staff were observed interacting supportively and positively with service users. Service users were observed choosing where they wished to spend their time and they were observed to freely approach staff when they wished to have a conversation or request assistance. The inspector observed written evidence that the menu options had been designed by a dietician. Specific dietary needs were catered for. The home is in the process of developing a photographic menu to assist service users when choosing the weekly menu. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.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, and 20 Service users have access to the local GP and a range of health professionals as required. Medication cupboards are orderly and medication is administered from the original labelled containers. EVIDENCE: It was evidenced from service users files that they were registered with a local GP, and that when necessary support was received from a range of health professionals. Letters confirming that the annual health check had been completed and the outcome was observed on service users files. The community physiotherapist visited a service user during the inspection. Members of staff stated that they had requested that the physiotherapist visit the service user after they had a number of falls. One service user spoke about having had a hospital appointment arranged after a change in their health needs. The medication cupboard was orderly. Medication is administered from the original containers, and the Inspector observed that each service user’s medication was stored in an individual tray in the cupboard and that records of medication administered are recorded on 12 week cards with photographs of the service users attached. Staff training records detail that staff receive training in the administration of medication. The Manager confirmed that staff 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 15 receive updates to this training bi-annually and in the alternate years staff complete a competency assessment. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Clear complaint and protection of vulnerable adult procedures are in place to safeguard service users. EVIDENCE: One complaint was logged in the complaints book, and this had been received from a neighbour with regard to a maintenance issue. The record detailed that this had been reported to the maintenance team for resolution. No other complaints were recorded. It was observed that the organisation has a clear three-stage complaints procedure that requires the home manager to respond to complaints within 7 days. The procedure also states that complainants can contact the CSCI at any time. A symbol version of the complaints procedure is available for service users, however it is not clear that the service users can comprehend this procedure. Staff stated that the service users know who to talk to if they have concerns. It was observed that a clear and sound protection of vulnerable adults procedure was held at the home, which included a chart that directed staff how to respond to an allegation of abuse. Most staff including the Acting Manager have attended Surrey’s Multi-Agency Protection of Vulnerable Adults training. The Acting Manager stated that those members of staff that have not received the training are waiting to receive applications for the next Surrey Multi-Agency Protection of vulnerable adults training, and in the meantime they have been booked onto the organisation’s internal training. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 17 The home has detailed policies for the management of service users finances, and the inspector was advised about the monthly audits in place. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 18 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 and 30 Although it is recognised that some redecoration has occurred in the last 12 months, areas of the home are beginning to look tired. EVIDENCE: The home was orderly and generally clean. Small areas of the home were dusty, for example the banister areas and under wardrobes. These areas must be built into the cleaning rota. Requirements made to repair the seal around the first floor bathroom, to clean the tiles in the ground floor bathroom, to remove a rusty nail and to repair walls in the bedrooms had been completed. Service users bedrooms were orderly, and were observed to be highly personalised, and furnished to meet service users needs. Although it is recognised that carpets had been replaced and some redecoration had taken place in the past 12 months, the décor in areas of the home was beginning to look tired. The home must consider how to rectify this as part of the development plan. This plan was not available at the time of the inspection, and the new Acting Manager had not been involved in its development. This will be looked at in more detail at the next inspection. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 19 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) 34, 35 and 36 The organisations recruitment procedures and training ensures that service users are safeguarded. EVIDENCE: Staff personnel files were sampled during the inspection. Two written references were obtained for members of staff, however the home must ensure that written references are obtained from the previous employer’s HR department or a senior manager. It was observed that the organisation has clear recruitment procedures. CRB checks had been completed for all members of staff, original checks are held at head office, and a list of reference numbers are held at the home. These checks must be held at the home for inspection by the CSCI. The Inspector observed training records for all of the staff. This record showed that staff had received mandatory training and those that had not received updates to this training were in the process of being booked on to training courses. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 20 Staff advised the inspector that they now received regular supervision. The organisation should ensure that all staff receive regular supervision and that annual appraisals are completed. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 21 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 The new Acting Manager must apply for registration with the CSCI. EVIDENCE: The home has a new Acting Manager in post. The Manager advised the inspector that the had worked for the organisation for many years and they were in the process of completing NVQ Level 4 in Care and had registered to complete the Registered Managers Award. The Acting Manager must apply for registration with the CSCI without delay. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x 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 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x x Standard No 11 12 13 14 15 16 17 x 2 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 5 Gloucester Road Score x 3 x 3 Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 23 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 1 Regulation 4,5,6 Requirement The completion of the review of the statement of purpose and service users guide must be made a priority. Pre-admission assessments must be obtained for all service users where possible. The review of risk assessments must be completed. Service users lifestyles must not be affected by staffing levels. The home must consider how to include the improvement of the homes decoration in the development plan. The cleaning of the banister area and areas under wardrobes must be included in the cleaning roster. The organisation must ensure that references obtained from previous employers are from the previous employers HR department or a senior manager. Original CRB checks must be held at the home for inspection by the CSCI The new Acting Manager must apply for registration with the CSCI without delay. Timescale for action 16/07/05 2. 3. 4. 5. 2 9 12 24 14 13(4) 18(1) 23 16/08/05 16/07/05 16/06/05 16/08/05 6. 24 23 16/06/05 7. 34 19 16/06/05 8. 9. 34 37 17(2) 8,9 16/07/04 16/08/05 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 24 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. 2. Refer to Standard 6 Good Practice Recommendations The Organisation should ensure that all staff receive regular supervision and appraisal. 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 25 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 5 Gloucester Road H58_s13511_Gloucester Road (5)_v233711_160605_stage4.doc Version 1.30 Page 26 - 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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