Inspection on 25/07/05 for Fengates (1)

This inspection was carried out on 25th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fengates (1) 03/04/09

Fengates (1) 03/04/07

Fengates (1) 08/12/05

Fengates (1) 01/12/04

Fengates (1) 05/07/04

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

CARE HOME ADULTS 18-65 Fengates (1) 1 Fengates Redhill Surrey RH1 6AH Lead Inspector Lisa Johnson Unannounced 25th July 2005 1:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fengates (1) Address 1 Fengates Redhill Surrey RH1 6AH 01737 778811 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CMG Homes Ltd The Pointe, 89 Hartfield Road, Wimbledon, London, SW19 3TJ Miss Kate Charlotte Webber Care Home (CRH) 6 Category(ies) of Learning disability (LD) 6 registration, with number Mental disorder, excluding learning disability or of places dementia (MD) 2 Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The Home may accommodate up to 2 residents with both LD and MD within the total number of residents accommodated 2 The age/age range of the persons to be accommodated will be 19 TO 45 YEARS Date of last inspection 01 December 2004 Brief Description of the Service: 1 Fengates is owned by Care Management Group. The home is a detached property providing accommodation to six adults who have learning disabilities. The home is located in Redhill, Surrey. The home is accessible to local shops and public transport. Redhill town centre is close by. The accommodation is provided over two floors. All bedrooms are single with en-suite showers. There is a comfortable lounge, separate dining room and a large kitchen. There is a patio area and a small garden that is laid with lawn to the rear of the house. Parking is available at the front of the house. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over three and half hours. The main focus of the inspection was to review any requirements made at the last inspection. A tour of the premises took place. Care plans, policies and procedures and other required documents were sampled. The inspector spoke to two service users who live in the home and two members of staff. The inspector would like to thank the service users and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection? No requirements or recommendations were made at the last inspection. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 6 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. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5. Detailed information was available that would assist prospective service users and relatives make an informed choice as to whether the home would be a suitable place to live. Pre admission assessments were completed and visit and trial stays accommodated. Each service user is issued with a contract. EVIDENCE: A comprehensive statement of purpose is in place, which clearly describes the aims and objectives of the home and the facilities it is able to offer. Pre admission assessments are completed and trial visits and stays are accommodated and are flexible to the needs of the service users. Each service user is provided with a contract that was sampled on individual’s files. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 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 standard(s) 6, 8 & 9 The home demonstrates that it has developed and agreed with individual a care plan that is based on assessment including risk taking. Goal plans are implemented and reviewed. Service users are supported to make decisions and participate in the home. EVIDENCE: Each individual had a comprehensive care plan in place, which was based on assessment. There was a key worker system in place and it was evident that plans were reviewed, updated and recorded. Each plan contained a pen picture, strength and needs list and individual preferences. Risk assessments were detailed and in depth covering health, physical, emotional and life skills. It was clear that service users are involved in the care plans and they were signed. Quality assurance systems were implemented and monthly residents meetings take place. It was clear through documents that service users are supported to make choices and decisions in their lives and support is provided where required. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 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 standard(s) 11, 12, 13,14 & 15 Service users are given opportunities for personal development and participate in appropriate recreational and leisure activities. They have the opportunity of perusing their own interests and are supported to maintain links with families and friends EVIDENCE: The home supports service users to lead fulfilling lives. Plans sampled indicated that service users attend recreational activities including college, art therapy, pottery, and aromatherapy and leisure pursuits such as bowling, cinema and planning holidays. At the time of the inspection a majority of service users were returning from day activities. Staff were observed to be interacting with residents playing board games that were chosen by service users. Service users who wished to be alone had their rights respected. Some service users were observed to be making themselves drinks in the kitchen. Service users are given opportunities to take part in household tasks such as cleaning, vacuuming, shopping and one service user was observed to be undertaking laundry. One service user enjoys cooking and another service Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 11 user stated that she does a lot of activities, which she described as well as maintaining links with her family. The service user also had access to a phone. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 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 standard(s) 18, 19 & 20 Individuals receive support in the way they prefer. The healthcare needs of service users were assessed and appropriate support is implemented with specialist health care accessed when required. Service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Care plans clearly identify health needs and plans have been implemented based on detailed assessment. The personal likes, dislikes and preferences of individuals are recorded. Detailed risk assessments and management guidelines were in place for service users who require psychological and emotional support. Care plans sampled indicate that service users have access to the GP, opticians, dentist and other health care professionals when required. Medication records were sampled and were maintained adequately. A list was in place for staff who are trained and able to administer medication and storage of medication was satisfactory. Accident and incident records were sampled and documented appropriately. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home is able to demonstrate that there is an accessible complaint policy in place and that service users concerns are listened to. Policies and procedures were in place to protect service users from abuse. EVIDENCE: A clear complaint policy is in place, which was maintained in the Statement of Purpose and service user guide. A record of complaints was maintained. The book was sampled and it was clear that complaints were actioned and dealt with appropriately. A protection of vulnerable adults policy was in place including whistle blowing. The home has obtained the updated local authority protection of vulnerable adults policy. A member of staff spoken to confirmed that she had received appropriate training. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26,27,28 & 30. Service users live in a comfortable home that is furnished and decorated well. Bedrooms are comfortable and are personalised to individual tastes. Service users have adequate toilet and washing facilities that provide privacy and meet their needs. The home is kept clean and hygienic. EVIDENCE: The service presents a homely atmosphere and is decorated and well maintained to a high standard. The home has had some redecoration work and has obtained some new furniture in the sitting room. Bedrooms observed on this inspection were well furnished and personalised with possessions and belongings to reflect individual tastes and interests. All of the bedrooms have en-suite showers. A separate bathroom and adequate toilets were available which were clean and hygienic. There is a large sitting room and separate dining room, which were comfortable, and well furnished. There is an accessible kitchen, which was clean and hygienic, and evidence was observed that food hygiene legislation was adhered to. A separate utility room is available and is situated outside to the rear of the house. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 15 Records for regular maintenance and checks were in place. Ventilation and lighting was satisfactory. There was a small pleasant garden which was wellmaintained. Garden furniture was available for the comfort of service users. A recommendation was made that the home considers installing a separate area for smoking. It was reported that one service user smokes, although minimally and has his cigarette inside the entrance to the house. This will promote the health and wellbeing of all service users and staff in the home. The office area is small and cramped and consideration should be given as to whether this area can be enlarged. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 36 Staffing levels were adequate to meet the needs of the service users. Staff are supported to undertake training and development. Formal supervision is implemented to ensure that staff are competent to carry out their job. EVIDENCE: The duty rota was sampled and staffing levels were adequate to meet the needs of service users. There are three staff on during the day and two staff on at nighttime. Due to the manager and deputy not being available on this inspection access was not available to sample staff personnel files and records. However the staff member in charge of the shift confirmed that she was well supported by the manager and that she had completed an induction programme when she had commenced employment. Other training completed included mandatory training including health and safety, medication training and was completing a National Vocational Qualification. Two members of staff confirmed that they received regular supervision from the registered manager. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38, 39 & 42 The management of the home creates an open and positive atmosphere. The home has implemented quality assurance systems based on seeking the views of service users. The health and welfare of service users are protected and promoted. EVIDENCE: The registered person has been undertaking the Registered Managers Award and has the experience to manage the home. Staff spoken to confirmed that they were supported in their role. The home portrayed an open and positive atmosphere. A quality assurance system has been implemented where service users are given the opportunity to make comments about the service they receive. The home also holds residents meetings, which were sampled. The responsible individual carries out quality visits and makes reports available. A number of health and safety policies were sampled including fire records and maintenance, environmental risk assessments, control of harmful substances, water certificates, emergency lighting maintenance and food safety checklists. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 18 These procedures were all up-to-date and signed by staff to indicate they have read and understood them. Service users monies were sampled and records were maintained and documented adequately. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 19 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fengates (1) Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 20 No 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 Regulation Requirement No requirements were made. Timescale for action 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. Refer to Standard 24 Good Practice Recommendations the registered individual should consider installing a separate area for service users wishing to smoke to protect the health and welfare of service users and staff and consideration should be given to look at optons for extending the office. Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fengates (1) H58 S13437 1 Fengates V229809 250705 Stage 4.doc Version 1.30 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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