Inspection on 03/05/07 for Ethel Road (7)

This inspection was carried out on 3rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 8 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) 09/10/06

Ethel Road (7) 03/02/06

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 Vera Bulbeck Unannounced Inspection 3rd May 2007 14:30 Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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.V336605.R02.S.doc Version 5.2 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 9th October 2006 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 accommodation within the home is a communal lounge, dining room, conservatory and domestic style kitchen. The resident has a single bedroom with an en-suite bathroom and toilet. The service is privately owned, provides a caring and supportive environment and is run as an ordinary domestic household. The fees are approximately £524.00 per week. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over three hours thirty minutes commencing at 14.30 and ending at 18.00. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. The care provided was sampled and the care observed for the resident. The resident was spoken too and was involved with the site visit process. The registered manager was present throughout the inspection. There was one resident living in the home on the day of the site visit. The inspector would like to thank the resident and the registered manager for their co-operation and hospitality during the inspection. The service user living in the home wished to be referred to as a resident, therefore service user will be referred to as resident throughout the report. What the service does well: What has improved since the last inspection? Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 6 It was difficult for the inspector to evaluate any improvements to the home. This was the first visit to 7 Ethel Road by the inspector; therefore it was difficult to make a judgement. The pre inspection questionnaire, which had been sent out to the home, was not available, therefore there was no information provided by the management of the home to assist in the inspection process. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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.V336605.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s needs are met and he lives as part of the family, in a family home. EVIDENCE: The resident has lived with the family for the past ten years and therefore a pre assessment has not been undertaken. The home operates on a family home basis. The resident was fostered by the family ten years ago, and when he reached the age of eighteen years the family registered the home to enable the resident to continue living with the family. He refers to the younger children as his younger brothers and feels part of the family. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The resident is encouraged to live an independent life as much as possible. There are gaps in the recording of the care provided therefore, personal gaols had not been identified. EVIDENCE: There was no care plan in place to assess if the care provided was meeting the needs of the resident. The resident informed the inspector he is involved with the care he receives. The last recorded entry on the daily record was dated 03/01/06. Risk assessments were found to be out of date these were dated 05/01/01. The review of assessed needs was dated 24/02/06 and it was documented the next review was due in February 2007. This needs to be followed up with the care manager. The resident is treated as a member of the family. The resident informed the inspector that when he needs help he is able to ask and help is provided. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 10 However, he is encouraged to be as independent as possible. He is able to live a busy life he normally goes out on a daily basis five days a week to a college. However, on a trip to Lego land a leisure park with the family he fell and broke his ankle, and he was informed by the hospital to rest his ankle as much as possible. On the day of the first visit to undertake an inspection, the resident and the proprietor had been at the fracture clinic all day and the resident informed the inspector he was tired and wanted to lie down. The inspector agreed to change the day and went back the following day to undertake the site visit. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident has the opportunity for personal development and to take part in appropriate activities within the home and in the local community. He is supported to maintain and develop appropriate personal and family relationships. EVIDENCE: The resident normally goes to college five a week and undertakes a number of activities for example, cooking, craft, news and views, painting, and plays various sports including volley ball, which he enjoys. He also attends an evening club and plays darts, dominos, bowling and particuarly enjoys the karaoke night. He also enjoys going to the theatre. His hobby is photography and has a new camera, which he is very proud of and showed the inspector some of his photographs. He also enjoys watching horror DVD’s. On the day of the site visit the resident and the proprietor had been to the market, the resident informed the inspector that he had purchased Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 12 a DVD and some CD’s. He also stated that he shuts his bedroom door when he is watching these films, as the two other children are not old enough to watch these films. He stated that when his door is shut the children knock on his door if they want him but they do not go into his bedroom without being invited in. The resident goes to visit his family most weekends for the day. He also has an advocate who takes the resident out on a regular basis either during the week or at weekends. However, because of the resident’s fracture he has not been out for several weeks. The inspector was informed by the resident some of the places he has visited for holidays, these include Menorca, Tunisia, Turkey, Cyprus, Greece and India. Holidays are taken with the family and it was very clear the resident is very happy in his environment. Mealtime was not observed, as the proprietor works single-handed and would be cooking the evening meal for the whole family. However, the resident stated he enjoys his meals and will eat most foods he is given. But he does enjoy going to Mc Donald’s. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and is provided, where needed, in a respectful and sensitive manner. EVIDENCE: The resident was able to inform the inspector that he receives the care and support he needs in a respectful manner. It was clear that his health care needs are being met, particuarly with the number of visits to the hospital and doctor in the last few weeks. Records need to be kept up date to verify the residents health care needs are being met. The resident does not take any medication therefore medication was not observed. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Policies are in place to protect the resident from abuse and neglect but lack of training and recruitment procedures are placing the resident at the possible risk of harm and abuse. EVIDENCE: The resident informed the inspector he does not need to make a complaint if he has any problems he is able to speak with the proprietor. The registered manager stated there have not been any complaints received in the home, there are procedures in place in the event of a complaint. The Commission for Social Care Inspection have not received any complaints or concerns. There was a copy of Surrey Multi Agency Procedures this was dated 2005 and up to date. The registered manager needs to complete the training for the protection of vulnerable adults; this has been a requirement for some considerable time. The resident’s finances were not available on the day of the site visit. The registered manager informed the inspector that she had given the records and money to the advocate to audit. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The house is a busy home the resident has his own personalised bedroom and en-suite bathroom. EVIDENCE: The home is homely and a family home, the resident’s bedroom is on the ground floor, he has his own single bedroom and a bathroom with a toilet next to his bedroom. The family sleep on the first floor of the home. The resident informed the inspector he allows the younger children to watch television in his bedroom, but if he closes the door they do not bother him. The home has an extended family of four dogs, a rabbit, two tortoises and a fish tank. The toilet on the ground floor next to the kitchen needs to be reviewed. The proprietor informed the inspector mainly her two young children use the toilet. The resident has his own toilet. Currently the toilet is without a door, this Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 16 practice is somewhat unhygienic and any toilet particuarly next to the kitchen should have a door. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The proprietors provide the staffing arrangements twenty-four hours a day, apart from time to time when the proprietors go out and a relative stays with the family. The advocate involved with the resident needs to have an up to date CRB undertaken. EVIDENCE: There are no staff employed in the home, the registered manager is the sole person who cares for the resident and her family. However, the resident has an advocate and there were no records available of this person. The registered manager stated that the person is employed elsewhere and has been checked with the Criminal Records Bureau (CRB) in her current job. The inspector advised the proprietor that she must undertake a CRB on any person working in the home or having contact with the resident in the home. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home needs to undertake appropriate training courses to ensure the resident is safe and protected from harm and abuse. The maintenance of keeping records up to date and in some order needs to improve. EVIDENCE: The registered manager needs to complete a number of training courses. Training needs have been outstanding for some considerable time, even the most basic courses have not been undertaken. All mandatory training needs to be undertaken including food hygiene, first aid, fire training, medication and the protection of vulnerable adults. Equality and diversity training needs to be undertaken. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 19 A number of records were checked and the majority were found to be out of date or not available. For example the testing of the batteries in the fire alarm system was last recorded on 03/02/06. Cleaning materials are stored under the kitchen sink with a child lock. There were no certificates available for the testing of electrical appliances, or the testing for Legionella. The registered manager informed the inspector that she has a contract with a company in the event of any problems the company would visit the home and put matters right. There was also no gas certificate but again the proprietor has a contract for any gas appliances that may go wrong the company would repair the boiler. The manager needs to maintain a record of the food served in the home and the temperature of cooked meat needs to be undertaken on a regular basis, and must be recorded. The registered manager needs to attend a food hygiene course. The certificate of registration needs to be changed as the present certificate is referring to the NCSC. The inspector has organised a new certificate to be sent. The home insurance certificate was not available. However, the proprietor informed the inspector she had contacted the Insurance Brokers to establish if the home was covered for business purposes. It was agreed that she would contact again and ask for this information in writing and send a copy to the Commission for Social Care Inspection. Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 1 X X 1 X Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 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 Standard YA20 Regulation 18(1)(c)(i) Requirement That the manager attends updated training regarding medication, or another person with certifiable evidence of training and attached to the home can be confirmed. This will be the fourth time this requirement has been made (Previous time scale of 01/04/06 not met and 09/12/06 not met). A new timescale for completion has been agreed. Timescale for action 24/09/07 2. YA23 9(2)(b)(i) The manager must ensure 24/09/07 that arrangements are made by training to prevent the resident from experiencing harm or suffering abuse or being placed at risk of harm or abuse by attending the next available Safeguarding Vulnerable Adults Training with Surrey County Council details of booked training to be sent to CSCI. (Timescale DS0000013530.V336605.R02.S.doc Version 5.2 Page 22 Ethel Road (7) 09/12/06 not met). 3. YA23 Schedule 4 Para (9)(a) The manager must ensure that accurate records of residents financial transactions are made and receipts kept and recorded. (Timescale 09/12/06 not available in the home). A care plan must be produced for the resident. The toilet off the kitchen must have a door. The registered manager to demonstrate the action is progressed within agreed timescales to implement requirements identified in the inspection report. Details records must be maintained at all times. The registered manager must attend a number of training courses to ensure the home is managed appropriately. 29/06/07 4. 5. 6. YA6 YA30 YA39 15 16(2)(j) 10 29/06/07 24/09/07 24/09/07 7. 8. YA41 YA42 17 19 29/05/07 24/09/07 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 3 4 Refer to Standard YA9 YA10 YA35 YA39 Good Practice Recommendations It was recommended that the home update encounter records and also include a record of risk assessment. (Not met from previous inspection). It was recommended that the residents care plans and other documentation be kept in a locked storage area. (Not met from previous inspection). It is recommended that health and safety and food hygiene be timetabled for consideration and training updates for NVQ. (Not met from previous inspection). It was recommended that the home review the quality of DS0000013530.V336605.R02.S.doc Version 5.2 Page 23 Ethel Road (7) care by completing a Quality Assurance review. (Not met from the previous inspection). Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ethel Road (7) DS0000013530.V336605.R02.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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