Inspection on 03/02/06 for Ethel Road (7)

This inspection was carried out on 3rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 5 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) 21/10/05

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 3 February 2006 11:00 rd Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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.V280971.R01.S.doc Version 5.1 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.V280971.R01.S.doc Version 5.1 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.V280971.R01.S.doc Version 5.1 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 21st October 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.V280971.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 3rd February 06. The duration of the inspection was 2 hours. As part of the inspection process discussion was held with the provider/manager and the resident. The residents care manager was contacted subsequent to the inspection regarding their opinion of the service provided. The care manager was satisfied with the service and had no concerns from his contact with the home. Samples of policies, procedures and records were examined. A full tour of the premises was not undertaken on this occasion. Most of the ‘core’ Standards were assessed at the previous inspection, therefore only the remaining core Standards were scrutinised on this occasion. Most of the requirements set at the previous inspection were evidenced as being met or were in progress; however a small number remained outstanding and these must now be addressed. The inspection was positive with evidence of good outcomes for the resident. The service provided is that of an ordinary family household and the resident is accepted and treated as ‘one of the family,’ having lived at the home for eight years. The resident stated in discussion that he was ‘part of the family’ and that he was settled and happy in his environment. He stated that he had no complaints or concerns about the service and that he felt safe in his placement. The home is maintained in good order throughout, has high standards of cleanliness and hygiene and had no safety hazards evident. Policies, procedures and records were in place and generally well kept though some needed expansion and the fire risk assessment needs to be completed. A small number of requirements are made. What the service does well: The service provides a caring, supportive and accepting environment for the resident. Its strengths are in caring for the resident as part of the family and including him in all aspects of their daily living / family routines. Sound relationships between the resident and the service providers and their family have been established over many years and are maintained. The resident spoke favourably about his placement and stated he was happy with all aspects of care provided. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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.V280971.R01.S.doc Version 5.1 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.V280971.R01.S.doc Version 5.1 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): 4. The resident was admitted to the home in a planned way. EVIDENCE: The resident first came to the home as a ‘fostering’ placement many years ago and followed the admission procedures at that time. There have been no admissions to the home since then. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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. The resident is enabled to take day-to-day risks and a written risk assessment is in place; however the assessment needs to be updated. EVIDENCE: A written risk assessment is in place regarding the current resident. Whilst the risk assessment is detailed it needs to be reviewed and evidenced as ‘updated’ although the manager stated that no changes in the assessment are likely. The resident is enabled to take day-to-day risks commensurate to his level of ability and this was confirmed by the resident in discussion. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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): 15 and 16. Relationships within the placement are harmonious and established with the resident being accepted as part of the family. The resident maintains contact with his immediate and extended family and friends. EVIDENCE: The resident is accepted as part of the family and relationships between them were evidenced as harmonious. The resident stated in discussion that he is part of the family and is settled in his environment. It was evidenced via written records that the resident has contact with his immediate and extended family and also has contact with friends in the community. The home’s routine is that of an ordinary domestic household and the resident was observed to have adequate degrees of autonomy and privacy. The resident stated in discussion that he enjoyed living in the home and was ‘part of the family’. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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): 18. The resident is supported consistent with his assessed needs. EVIDENCE: The resident is provided with support consistent with his needs. The resident is independent for the most part; however he needs assistance with shaving. Areas of support are detailed in the residents care plan. The resident stated that he is able to do things for himself and support is always there if required. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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): 22 and 23. The home has regard for the areas of complaints and protection regarding the resident. EVIDENCE: The home has a written complaint procedure and a complaint form is available for the resident. The complaint form evidenced that no complaints have been received and the resident stated in discussion that he had no complaints about the service he receives. The resident added that he was has always liked living at the home and being part of the family. The resident has an ‘advocate’. The home has a policy and procedure regarding the Protection of Vulnerable Adults and also holds the revised Surrey County Council Multi-Agency Procedures in the Protection of Vulnerable Adults. The manager stated that her husband and (co- service provider) receives training in the protection of Vulnerable Adults via his employment as the manager of a day centre with a London Borough. It was a requirement at the last inspection that the manager attend the Surrey County Council MultiAgency training in the protection of Vulnerable Adults. It was evidenced that the manager had contacted that Adult Protection training section and was awaiting a response from them. As action had been initiated regarding this, a further requirement will not be made. It was evidenced that the manager keeps a written record of the resident’s income/expenditure. The resident stated that he felt safe in his placement and that he was looked after properly. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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): 30. The manager/providers have regard for maintaining standards of cleanliness and hygiene throughout the home. EVIDENCE: The home has a policy and procedure regarding ‘infection control’. Standards of cleanliness and hygiene were high throughout the home and no safety hazards were evident. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 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): 36. The manager/providers support each other in the management of the home, which enables a very good standard of care to be afforded to the resident. EVIDENCE: The household functions as an ordinary family and does not employ staff. The manager/providers have substantial experience in caring for people with learning disabilities and work as a close and consistent team. The manager keeps abreast of developments by obtaining relevant information and publications etc. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 Page 15 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): 39 and 42. The service is monitored as part of the daily living routine of the family. The home has regard for health and safety matters; however it is important that the fire risk assessment is completed and the home’s insurance liability cover is checked with the insurance company to see if the current cover provided is appropriate for the service. EVIDENCE: The home has an internal quality assurance questionnaire and a pre-review questionnaire. The questionnaires are due to be completed next on 24th February 06. The service is monitored on a regular basis by the manager/providers. As one of the service providers is also the manager, Regulation 26 visits and reports are not necessary. Whilst there have been several changes of care manager recently, there was evidence of visits and contact with the resident. The home has a health and safety policy statement. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 Page 16 The home had a new fire risk assessment form; however this had not yet been completed. It is important that this is completed and a requirement will be made regarding this. There was evidence of fire alarm tests occurring on a weekly basis, the most recent being on 3rd February 06. The home had a gas test certificate and this is due for renewal in June 06. It was also evidenced that the electricity system will be tested by the same Gas Company in June 06. As this is in progress a requirement will not be made. The home had written information available regarding Legionella; however a written risk assessment had not yet been drawn up. It is important that such an assessment is drawn up and a requirement will be made regarding this. The home had a current insurance liability certificate; however this did not cover insurance to the sum of 5 million pounds. It is important that the manager check with the insurance company to see if the current cover is appropriate for the service. The home’s accident forms were available. The forms evidenced that no accidents had occurred. No safety hazards were evident regarding the premises. Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 Page 17 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 X 2 X 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X X X 3 X X 2 X Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 Page 18 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. Standard YA9 Regulation 13, (4) © Requirement That the residents Risk Assessment is reviewed and updated as appropriate. Timescale for action 15/03/06 2. YA43 25, (2) (e) That the manager checks with its 15/03/06 insurers to see if its current liability certificate provides adequate cover for the service provided to the resident. (Previous time scale of 10/11/05 not met.) That a written risk assessment 15/03/05 regarding Legionella is drawn up. That a written fire risk 15/03/06 assessment is drawn up. That the manager attends 01/04/06 updated training regarding medication. (Previous time scale of 10/12/05 not met.) 3 4 5 YA42 YA42 YA20 13, (4) © 23, (4) 18, (1) (c ) (i) Ethel Road (7) DS0000013530.V280971.R01.S.doc Version 5.1 Page 19 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.V280971.R01.S.doc Version 5.1 Page 20 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. 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