Inspection on 13/12/05 for Fengates Road (5)

This inspection was carried out on 13th December 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 Road (5) 24/08/06

Fengates Road (5) 25/07/05

Fengates Road (5) 20/12/04

Fengates Road (5) 07/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Fengates Road (5) 5 Fengates Road Redhill Surrey RH1 6AH Lead Inspector Lisa Johnson Announced Inspection 13th December 2005 10:00 Fengates Road (5) DS0000013510.V259753.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 Fengates Road (5) DS0000013510.V259753.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. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fengates Road (5) Address 5 Fengates Road Redhill Surrey RH1 6AH 01737 778858 01737 769005 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) CMG Homes Ltd Care Home 5 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (5) of places Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 5 residents with a mental disorder (MD) accommodated, up to 3 (three) may have a learning disability (LD). The age range of service users will be 18 - 40 years Date of last inspection 25th July 2005 Brief Description of the Service: 5, Fengates is owned by Care Management Group. The home is a semidetached property in Redhill, Surrey and is close to local amenities. The home provides accommodation to five adults who have learning disabilities and/or mental disorder. The home is a three-storey building and all the service users have their own bedrooms, which are situated, on the upper two floors. There is a communal lounge, dining room and a kitchen. There is a paved patio to the rear of the house. Parking is available at the front of the property. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection carried out in 2005/2006. One inspector carried out the announced inspection over four hours. The focus of the inspection was to review any requirements made at the last inspection and to look at other required standards. A tour of the premises took place and care plans, policies and procedures and other required documents were sampled. The inspector spoke to the home manager, one member of staff and three service users. Feedback comment cards were received from four service users; one from a relative and two cards were received from health and social care professionals. These comments are reflected in this report. 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: It was clear that service users were supported with a full programme of daily activities including a range of social events, which was seen during this inspection. This was confirmed by one service user who said, “ I go out a lot here” and another comment received was “ I do lots of things”. It was pleasing to see service users being offered choices and participating in life skills. From the comment cards received service users like living in the home and comments received were, “I get support from staff” and “ I like the staff”. The service provides a homely, welcoming and friendly atmosphere. The staff team have a good knowledge and awareness of the resident’s individual needs which is confirmed by comments received from health and social care professionals who have contact with the home. Fengates Road (5) DS0000013510.V259753.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. Fengates Road (5) DS0000013510.V259753.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 Fengates Road (5) DS0000013510.V259753.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 The home was able to demonstrate that prospective service users needs are assessed. EVIDENCE: Sine the previous inspection a service user has been admitted to the home and documentation was sampled. It was evident that a pre-admission assessment was completed. An induction assessment had been undertaken and a six-week initial review was completed. Fengates Road (5) DS0000013510.V259753.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 & 10 Each service user is provided with a completed care plan that is based on assessment. The home is able to demonstrate that goal plans are reviewed and that service users are involved in the review process. However one outstanding goal action plan should be competed. Confidential information is handled appropriately EVIDENCE: Care plans were sampled and each service user is issued with a comprehensive care plan outlining their health, emotional and social care needs. The plan is Person-centred and information consisted of a life picture and strengths and needs and service users sign their plans where possible. It was evident that regular reviews take place and this as confirmed by comments received from four individuals. Plans were supported with risk assessments and management guidelines. However one individual who was recently admitted to the home requires a written action plan and this was made a requirement. This is to ensure that a plan is in place as to how the service is going to meet the personal needs and goals of the individual. Comments received from health and social care professionals indicate that staff have a clear understanding of the needs of service users and that individual plans are in place and are followed. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 10 Service users files were kept secure in the office. A confidentiality policy is in place. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 The home is able to demonstrate that service users have fulfilling leisure activities and make use of community facilities .The staff have a good understanding of the service users’ support needs. This was evident from the positive relationships, which have been formed between the staff and service users. Service users are offered a well balanced diet. EVIDENCE: A range of recreational and social activities takes place. During the inspection it was evident that service users have busy and fulfilling lives. Staff were seen taking service users to day services and going out shopping. At the time of the inspection an aromatherapist was visiting the home. One service user said, “ I go out a lot here, I like to go out shopping to buy toiletries”. Some individuals attend classes at East Surrey College, visit the local leisure centre, go bowling, visit social clubs, go to the theatre, visit the cinema and go bowling. Service users maintain links with family and friends. One individual spoke about her friend that she maintains contact with. A relative commented that they are made to feel welcome and can visit at any time and is able to visit their relative in private in private. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 12 Service users were observed to be comfortable and relaxed in the company of staff. There was unrestricted access in the home and staff were seen to provide support when required such as assistance in the kitchen. Service users are offered their own door keys but choose not to use them. Menus were sampled and were varied and lunch was nutritious in content with a variety of sandwiches being offered. Staff were observed to offer choices Staff were well aware of the likes and dislikes of individuals. It was pleasing to see staff and residents enjoying eating lunch together in a relaxed atmosphere. One individual commented, “The menu is healthy”. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 The home is able to demonstrate that plans are completed in respect of service users wishes concerning dieing and death. EVIDENCE: The service users wishes in respect of death and dieing have been discussed and plans have been completed in agreement with individuals and signed by them. Fengates Road (5) DS0000013510.V259753.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 & 23 The home is able to demonstrate that there is an accessible complaints procedure. Written policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which is also in pictorial format and was on display in the home. The homes complaints log was sampled and no complaints have been received since the previous inspection. One service user spoken to stated “ I was told I can make complaints when I moved here” Four comment cards received confirmed that service users know whom to approach in the home if they had any concerns and feel safe. Two comments reflect that sometimes things are not so good when other residents get angry. A relative has confirmed that they are aware of the complaint procedure. The home has now obtained the local authority protection of vulnerable adults policy and a whistle blowing policy was in place. Staff training records were sampled which showed that staff are receiving training in the protection of vulnerable adults. Comments received from service users confirmed that those who provided feedback are happy living in the home, feel well cared for and feel safe. Fengates Road (5) DS0000013510.V259753.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, 29 & 30 Individuals live in a comfortable home that is clean and hygienic. The home needs to ensure that suitable and sufficient lighting is available in the dining room. EVIDENCE: The home is accessible to local shops and facilities. The service portrays a homely atmosphere. Communal rooms in the home are well decorated and furnished. There are plans to convert one bathroom into a shower room, as some individuals prefer this. However during the inspection it was noted that only one light bulb was working in the central light in the dining room making this room dark. An immediate requirement was made that this requires attention. This is to ensure that adequate lighting is available and to protect the safety and welfare of service users and staff. Call bell facilities are in place which are regularly tested and monitoring records are maintained The home was clean and hygienic. Infection control procedures were in place. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 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 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): 31, 32 & 34 Staff are aware of their responsibilities. Staff were supported to undertake training and development. Service users are protected by the homes recruitment policies and procedures. EVIDENCE: All staff are issued with job descriptions. One member of staff spoken to was clear about her role and responsibilities and receives regular formal supervision. A copy of the General Social Care code of conduct (GSCC) was present on staff files. A system of delegation is place by the manager. Staff training schedules were sampled and it was clear that staff have been undertaking a programme of training and development including mandatory training, medication training, key worker roles, understanding challenging behaviour and health action planning. An ongoing programme is in place for staff to complete National Vocational Qualifications. Staff personal files were sampled and now contained all of the required information. This ensures that service users are protected by the homes recruitment policies and practices. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 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 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, 40, 41, 42 & 43 The home reviews its performance by seeking the views of service users through a consultation process undertaken via an annual survey. The home has implemented adequate health and safety policies and procedures. However the manager should install radiator covers to ensure the safety and wellbeing of residents. Service users are protected by the financial procedures in the home. EVIDENCE: The company carries out a quality assurance questionnaire annually and outcomes are feedback to service users with an annual forum held. The home also holds regular service user forums. A range of policies and procedures were in place and were sampled including whistle blowing, access to records, confidentiality, staff conduct and equal opportunities. Adequate health and safety procedures were in place. One member of staff spoken is responsible for completing health and safety checks in the home. Records of checks and maintenance were sampled including electrical testing, Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 18 gas safety records water temperatures and legionella testing, regular records were in place for checking fridge and freezer temperatures. Fire records and equipment testing as up-to-date. Hazardous substances were stored appropriately and a food hygiene audit is completed weekly. However a requirement was made in respect of the radiator, which require covers. This is to ensure that the safety and welfare of service users is protected All service users have bank accounts, however some monies are retained in the home for service users. Records were sampled and were satisfactory. The company produces a business plan. However a recommendation was made that the home maintains an updated copy for the home. The company is responsible for the overall budget but the manager is responsible for holding and monitoring a budget for the home. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 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 X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fengates Road (5) Score X X X 3 Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 2 3 DS0000013510.V259753.R01.S.doc Version 5.0 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 YA 6 Regulation 15 (1) Requirement The manager must ensure that the care action plan is completed for one service user. This is to ensure as to how the service users personal goals are to be met and when they are to be reviewed. The lighting in the dining room must be addressed. The registered manager must ensure that radiator covers are supplied through out the home. This is to ensure the health and safety of service users Timescale for action 13/01/06 2 3 YA 24 YA 42 23 (2)(p) 13 (4)(c) 13/12/05 13/01/06 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 43 Good Practice Recommendations It is recommended that the home maintain an updated business plan. Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fengates Road (5) DS0000013510.V259753.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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