Inspection on 22/09/05 for East Surrey Carer`s Support Services

This inspection was carried out on 22nd September 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 found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

East Surrey Carer`s Support... 16/06/05

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 Inspection 22nd September 2005 13:45 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 5 Gloucester Road Address 5 Gloucester Road Redhill Surrey RH1 1BP 01737 765800 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) Prospect Housing and Support Services To be confirmed Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (3) of places 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the five (5) residents accommodated, up to three residents may fall within the category MD. The age/age range of the persons to be accommodated will be: 54 65 years. Accommodation and services may be provided to a named person aged 65 years, with the prior written agreement of the C.S.C.I. 16th June 2005 Date of last inspection 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 bathroom. 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 DS0000059966.V253684.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection for the inspection year 2005/2006. The inspection was an unannounced inspection, which means that neither the staff nor the service users were aware that the inspection was going to take place. The inspection was undertaken by Mrs Kerry Fell and took two hours to complete. The inspector observed records and met with two service users during the inspection. The inspection was focused upon the core standards that had not been inspected at the last inspection, and any requirements made at the last inspection. What the service does well: What has improved since the last inspection? The statement of purpose had been improved since the last inspection. This was found to be a detailed document and would not easily be forwarded to potential service users. The home also holds a “brochure” document, which generally contains the relevant information – however this would require additional information to be added, including fire procedures, if this is to be sent out. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 6 Risk assessments have been updated as required at the last inspection. Additional members of staff have been made available for activities and as required to ensure that service users’ lifestyles are not restricted. Supervision sessions are now taking place on a more regular basis. 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. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 The statement of purpose had been updated, and contained a lot of information. Pre-admission assessments are still to be sought. EVIDENCE: The statement of purpose had been updated since the last inspection. The statement of purpose file provided a great deal of information, but it would not be possible for the whole document to be sent to anybody who requested it. The brochure section of this file contained a colour document called the statement of purpose. This was a more useful document and was observed to contained a précis of most of the required information, the full complaints procedure, fire and emergency procedures and information about how service users are consulted must be included with this document when it is sent out. It was not clear during the inspection whether pre-admission assessments for the service users had been obtained. There had been no new admissions since the last inspection however; the home must continue to endeavour to obtain these. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 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 the following standard(s): 9 Risk assessments are up to date, and new ones are completed as required. EVIDENCE: Those risk assessments that required updating had been reviewed since the last inspection. The inspector also observed that new risk assessments had been completed as required. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Arrangements are made for additional members of staff to be available for activities. EVIDENCE: A discussion took place with regard to the home’s response to restrictions put upon the service users’ lives because of staffing levels. The inspector was advised that the home has been able to put in place additional staffing several times during the week or as required. The CSCI would strongly recommend that this continue. Service users spoken to during the inspection told the inspector about activities that they took part in. The home had hosted a garden party over the summer that both service users and members of staff spoke about positively. At the time of the inspection two service users were out at a workshop and one service user returned from a shopping trip. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this inspection. EVIDENCE: 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Members of staff are responding appropriately when supporting service users who may present challenging behaviour, however members of staff are not formally trained to do this. EVIDENCE: The inspector was aware from a number of notifications made to the CSCI Surrey Local Office as required under regulation 37 of the Care Homes Regulations 2001, that there had been an increase in the number of incidents of challenging behaviour. A discussion took place during the inspection about how the home was managing these incidents. The inspector was advised that behavioural guidelines had been rewritten and advice is sought from the community psychiatric nurse. Further discussions took place about what may have triggered any change in behaviour. The inspector was advised that appropriate action had been taken to investigate any possible causes for a change in behaviour. Although the inspector was advised that members of staff are confident in using the new guidelines. Members of staff have not received formal training in the management of challenging behaviour. Formal training in the management of challenging behaviour must be sought. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The home is neat and orderly. EVIDENCE: The home was found to be neat and orderly at the time of the inspection. A requirement was made at the last inspection with regard to ensuring that areas around the stairway and under wardrobes are included in the cleaning roster. The inspector observed that these areas had been cleaned. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 36 Although the home has a thorough recruitment procedure in place, original CRB checks are not held in the home, nor are they managed in line with CRB guidance. EVIDENCE: Personnel records were again sampled during this inspection. Original CRB checks were not available at the home. The home must ensure that original CRB checks are held at the home, this is a requirement carried over from the last inspection. The inspector observed that copies of CRB checks were held on the personnel file, this is not in keeping with CRB guidance on managing CRB certificates. The home must ensure that CRB checks are managed in accordance with CRB guidance and data protection. Original CRB checks must be held at the home, this is a requirement carried over from the last inspection. No new members of staff had been recruited since the last inspection; therefore the inspector could not verify whether references were now being requested appropriately from the previous employer. The inspector observed that the supervision records demonstrated that supervision sessions were regularly taking place. A discussion took place during the inspection about how staff are supported following incidents of challenging behaviour. The inspector was advised that 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 15 the home seeks appropriate support and advice, and concerns can be dealt with during supervision. Members of staff and service users are debriefed following incidents. Please also see comments made under standard 23. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality Management and Quality Assurance procedures are not available at the home. Detailed programmes of health and safety checks are completed, but some records need to be reviewed. EVIDENCE: As required at the last inspection, the CSCI Surrey Local Office has received an application for registration from the acting manager. The inspector was advised that a quality audit had been completed at the home in July 2005; however, an outcome from this had not been received by the home. Policies and procedures with regard to quality assurance could not be found at the time of the inspection, and an immediate requirement was left for the home to report to the CSCI Surrey Local Office about the organisation’s quality assurance and quality management procedures, this information had not been received at the time of this report being made draft. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 17 The inspector was provided with the home’s health and safety records. The inspector observed that health and safety policies were available in the home. Most staff had completed health and safety training updates, and those that hadn’t were booked onto training courses in the next few weeks. The member of staff who is responsible for health and safety within the home was present during the inspection. The inspector was impressed with the prompt action taken by the member of staff to find information and respond to queries made by the inspector. The inspector was observed that records health and safety checks were being maintained, however the inspector observed that the fire log was not being used consistently for recording evacuations. Although fire evacuation records were being kept on loose leaf internal forms, the home must take advice about how these records and the fire log are to be used to ensure that they are meeting the requirements of fire safety legislation. The inspector observed that water checks were completed, and the inspector was advised that showerheads were regularly cleaned. A record of when showerheads are cleaned should be maintained. The inspector observed that monthly health and safety checks of the home environment were completed. A gap was observed in these records between March and July 2005. These checks must be completed consistently. The inspector also observed that repairs identified in the July 2005 report were again reported in August 2005. Repairs must be completed promptly. Detailed health and safety risk assessments were available, and the inspector observed that all of these apart from the manual handling risk assessment had been reviewed. The manual handling risk assessment must be reviewed without delay. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 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 2 2 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 5 Gloucester Road Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000059966.V253684.R01.S.doc Version 5.0 Page 19 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 YA1 Regulation 4 Requirement The full complaints procedure, fire and emergency procedures and information about how service users are consulted must be included with the statement of purpose when it is sent out. The home must continue to endeavour to obtain preadmission documentation. Formal training in the management of challenging behaviour must be sought. Original CRB checks must be held at the home, this is a requirement carried over from the last inspection. The home must ensure that CRB checks are managed in accordance with CRB guidance and data protection. The home must take advice about how the homes records and the fire log are to be used to ensure that they are meeting the requirements of fire safety legislation. The outcome must be reported to the CSCI Surrey Local Office. DS0000059966.V253684.R01.S.doc Timescale for action 22/10/05 2 YA2 14 22/09/05 3 4 YA23 YA34 12, 13(6) 19(5) 22/11/05 22/09/05 5 YA34 19(5), 17 22/09/05 6 YA42 23(4) 22/10/05 5 Gloucester Road Version 5.0 Page 20 7 8 YA42 YA42 12 (1), 23(1) 13(4) Repairs must be completed promptly. The manual handling risk assessment must be reviewed without delay. 22/09/05 22/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA12 YA42 Good Practice Recommendations The CSCI would strongly recommend that the home continue to make additional staffing available to ensure that staffing levels do not affect service users lifestyles. A record of when showerheads are cleaned should be maintained. 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 5 Gloucester Road DS0000059966.V253684.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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