Inspection on 21/10/05 for Ethel Road (7)

This inspection was carried out on 21st October 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ethel Road (7) 21/04/10

Ethel Road (7) 28/10/09

Ethel Road (7) 23/10/08

Ethel Road (7) 22/11/07

Ethel Road (7) 03/05/07

Ethel Road (7) 09/10/06

Ethel Road (7) 03/02/06

Ethel Road (7) 24/01/05

Ethel Road (7) 11/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Ethel Road (7) 7 Ethel Road Ashford Middlesex TW15 3RB Lead Inspector John Chivers Unannounced Inspection 21st October 2005 11:00 Ethel Road (7) DS0000013530.V255374.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 Ethel Road (7) DS0000013530.V255374.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. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ethel Road (7) Address 7 Ethel Road Ashford Middlesex TW15 3RB 01784 240646 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 Victoria Charlton Mr Vaughan Charlton Mrs Victoria Charlton Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 18 - 35 years The gender of those accommodated will be Male Date of last inspection 24th January 2005 Brief Description of the Service: The home is registered as a care home within the service user category: Learning Disability. The home is registered for a maximum of one male resident. The service is privately owned. The service provides a caring and supportive environment and is run as an ordinary domestic household. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 24th October 05. The duration of the inspection was 1.5 hours. As part of the inspection process discussion was held with the resident and the manager of the home. The inspection included examination of a sample of the home’s policies, procedures and records. A tour of the premises was undertaken. The findings of the inspection were positive with observed evidence of very good standards of care practice and the provision of a homely and caring environment. A range of policies and procedures were in place and the home’s records were satisfactorily kept. It was noted that some requirements from the previous inspection remained outstanding and it is important that these matters are now addressed. The premises are well maintained and no safety hazards were evident. The resident stated in discussion that he had no complaints or concerns about the service provided and that he enjoyed living at the home and was accepted as ‘part of the family’. The resident’s care manager spoke favourably about the service provided. Whilst the home affords good quality care for the resident, attention must be paid to the outstanding requirements and those requirements identified at this inspection. What the service does well: The service is successful at providing a homely and accepting family environment and has a long-term commitment to the resident. The home works well with the resident’s health, medical and dietary requirements and monitors these areas closely. The resident joins in all aspects of the service providers ‘family’ life’ both within the home and in the local community. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 6 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. Ethel Road (7) DS0000013530.V255374.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 Ethel Road (7) DS0000013530.V255374.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): 2 and 5. The home ensures written needs assessments are in place and are reviewed on a regular basis. The home further ensured that the resident’s contract/terms and conditions of residence had been completed. EVIDENCE: There was evidence of written needs assessments on the resident’s file. There was evidence of the needs assessment being reviewed and the current review was scheduled to be held on the day of the inspection. This was also confirmed by the resident’s ‘care manager’. The resident’s contract/terms and conditions of residence was available. The updated contract was dated April 05. Ethel Road (7) DS0000013530.V255374.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): 6 and 8. The home has regard for ‘care planning’ and ensures that such plans are reviewed. The home has been successful in establishing the resident as ‘one of the family’ and encourages his participation in all aspects of family life. EVIDENCE: The resident’s care plan was available and was scheduled for review along with the needs assessment on the day of the inspection. The resident’s care manager also confirmed the review was to take place.. The resident stated in discussion that his care manager was visiting on that day in order to review and update his care plan. The resident stated that he agreed with the content of his care plan. The resident is fully accepted as a member of the family and contributes his views and opinions to family life. Over recent years he participated in family holidays in Cyprus and India. The resident stated in discussion that he “fits in” with family life and that his views are listened to. Ethel Road (7) DS0000013530.V255374.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, 13 and 17. The home has regard for providing the resident with purposeful activities and encouraging him to participate in the local community. The home is aware of the resident’s special dietary needs and this area is monitored closely. EVIDENCE: The resident attends college and a day centre and the resident’s weekly activity programme was available. Reports from the college and day centre were available. The resident stated that he enjoyed attending the college and day centre. The resident also confirmed that he attends venues in the local community and participates in family life and a range of activities. The resident sometimes attends activities and excursions with his advocate. The resident was observed to be operating his personal computer at the time of the inspection and appeared competent in its use. The home’s menu was available. The resident has a special ‘soft’ diet arranged by the dietician and other health care professionals. The resident stated that he enjoyed his meals. The home’s kitchen is of a domestic size, modern and well equipped. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 11 Provisions were safely and correctly stored and the refrigerator and freezer were kept at the required temperature. It would be important for the home to record the temperatures on a daily basis. A requirement will be made regarding this. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 12 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): 19 and 20. The home has regard for health and medical matters concerning the resident and this area is monitored closely by the home. Medication storage facilities are consistent with appropriate Regulations and Standards; however it is important that the manager receives updated training in medication administration. EVIDENCE: The resident’s health care history and other medical details are recorded on needs assessments and care plans. Such details are reviewed and updated as appropriate. The resident meets with his ‘genetic councillor’ on an annual basis and receives an ‘ECG’ yearly. The appointments and outcome are recorded. Visits to the GP and other health care professionals are recorded. The home had a policy and procedure regarding medication and written guidance from the Royal Pharmaceutical Society was held. The home had forms for the recording of any medication administered and medication is kept in a locked cabinet. The resident is not currently taking any medication. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 13 The manager stated that old or discarded medication would be returned to the pharmacy for disposal and a disposal form was held for the pharmacist to confirm disposal. It was noted that the manager has not received any recent training regarding medication. It is important that updated training is received and a requirement will be made regarding this. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home would take any complaint seriously and has regard for the safety and protection of the resident, however the manager needs to receive updated training in this area and obtain the updated procedures regarding the protection of Vulnerable Adults. EVIDENCE: The home’s complaint procedure was available. In addition the home held a simplified version of the procedure for the resident. Complaint forms were available. The manager stated that no complaints had been received by the home. During discussion the resident was clear that he had no complaints or concerns about life in the home and the service provided. The resident’s care manager was also of the same opinion. The home held the Surrey County Council Multi-agency Adult Protection procedures. It was noted however that the details held were the April 2001 procedures and the manager was asked to obtain the revised version dated February 05. A requirement will be made regarding this. The managers spouse and co-provider received Adult Protection training in January 05, however the manager had not received any recent training in this area. A requirement will be made that the manager attend the Surrey County Council Multi-Agency training in the Protection of Vulnerable Adults. The resident is responsible for managing his own spending money. The resident stated in discussion that he felt safe in the home and well treated by the service provider’s/manager. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. The home provides a very good standard of accommodation, which is homely, comfortable and free from safety hazards. EVIDENCE: The home is a semi-detached property and is situated in a quiet residential road close to a range of facilities and amenities. The exterior of the property is maintained in good order and the rear garden is well kept and free from safety hazards. The communal areas in the home are decorated and furnished to a very good standard and provide adequate space for the resident. The resident’s bedroom is of an equal standard and has been personalised with a range of possessions and items. Toilet and bathing facilities are of a good standard and afford adequate privacy. With the exception of a back support attached to the resident’s bed and handrails fitted to the bath, the home does not have any other specialist adaptations or equipment. The resident stated that he was “happy” with the standard of accommodation provided and was “happy” and content” living at the home. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 16 Standards of cleanliness and hygiene were high throughout the home and no safety hazards were evident at the inspection. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): The service functions well as an ordinary domestic household and is successful at meeting the needs of the resident. EVIDENCE: The service is provided by a ‘husband and wife’ team and no staff are employed within the service. The CSCI Surrey Local Office carried out the required vetting procedures on the service providers as part of the registration process. The service functions a normal ‘family’ household. The spouse of the provider/manager is manager of a ‘day centre’ for people with learning disabilities with a London Borough Social Services Department. The manager stated that her husband receives a wide range of training as part of his employment with the borough. The manager stated that she has not received any training since the last inspection. It is important that some relevant training courses are attended, particularly in the area of Multi-Agency Adult Protection training and medication administration. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 and 43. The home is well managed and affords a very good standard of care to the resident; however it is important that the manager embarks on NVQ level 4 training in management and care. EVIDENCE: The manager holds the ‘BTEC’ qualification in Social Care and has substantial experience of working with adults with learning disabilities and has managed their current provision for approximately ten years. In acknowledging that the service functions as a normal ‘family’ household it is nevertheless important that the manager undertake NVQ level 4 training consistent with Standard 37. 2 (ii) of The National Minimum Standards for Care Home’s for Younger Adults. A requirement will be made regarding this. The manager stated that the home’s insurance company had not yet forwarded the certificate of insurance to the home. A requirement will be made that the insurance certificate is evidenced to the CSCI Surrey Local Office upon receipt. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 19 The service provider is also the manager of the home; therefore Regulation 26 visits are not applicable. Despite this it was evidenced that the service is managed and monitored in a satisfactory and consistent way and affords a very good standard of care to the resident. The resident’s previous care manager was complementary about the service and this was also the opinion of the current care manager. Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ethel Road (7) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X 2 X X DS0000013530.V255374.R01.S.doc Version 5.0 Page 21 Yes 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 2 Standard YA42 YA42 Regulation Requirement Timescale for action 10/11/05 10/11/05 3 YA23 4 YA23 5 YA43 6 YA37 7 YA20 13, (4) (c) That the home takes and records its refrigerator and freezer temperatures on a daily basis. 13, (4) (c) That the home arranges to have its electrical system tested and certified as safe. (Previous time scale of 28/2/05 not met.) 13, (6) That the home obtains the updated version of the Surrey County Council Multi-Agency Adult Protection procedures. 13, (6) That the home’s manager make arrangements to attend the Surrey County Council MultiAgency Adult Protection training course. 25, (2) That the home evidence receipt (e) of its current insurance liability certificate and ensure this covers public liability to the sum of £5 million. (Previous time scale of 01/2/05 not met) 9, (2) (b) That the home’s manager makes (i) arrangements to undertake NVQ level 4 training in management and care. (Previous time scale of 01/4/05 not met. 18, (1) (c That the manager attends ) (i) updated training regarding medication. DS0000013530.V255374.R01.S.doc 10/11/05 01/01/06 10/11/05 01/01/06 01/12/05 Ethel Road (7) Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 23 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 Ethel Road (7) DS0000013530.V255374.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!