Inspection on 25/07/05 for Fengates Road (5)

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fengates Road (5) 24/08/06

Fengates Road (5) 13/12/05

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 Unannounced 25 July 2005 9:00 th 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 Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 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 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 Care Home (CRH) 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) 5 of places Learning disability (LD) 3 Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the 5 residents with a mental disorder (MD) accommodated, up to 3 (three) may have a learning disability (LD). 2 The age range of service users will be 18 - 40 years Date of last inspection 20 December 2004 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 accomodation to 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 kichen. There is a paved patio to the rear of the house. parking is available at the front of the property. Fengates Road (5) H58 S13510 5 Fengates Road V229812 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 and care plans, policies and procedures and other required documents were sampled. The inspector spoke to the home manager and two service users. The inspector left some feedback forms and a business card. The inspector would like to thank the service users and staff for their hospitality and cooperation during this inspection. What the service does well: What has improved since the last inspection? A recommendation was made at the last inspection that records are archived and this has now been completed. Fengates Road (5) H58 S13510 5 Fengates Road V229812 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 Road (5) H58 S13510 5 Fengates Road V229812 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 Road (5) H58 S13510 5 Fengates Road V229812 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 Adequate 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 implemented. Trial visits are accommodated and each individual has a written contract in place. EVIDENCE: There was a comprehensive Statement of Purpose in place, which clearly describes the aims and objectives of the home and the services and facilities that it is able to offer. Pre admission assessments take place. Prospective service users and relatives are given the opportunity to visit the home and the home is able to accommodate a visit for a meal or overnight stay. Individual contracts were in place and signed where possible by the service user. Fengates Road (5) H58 S13510 5 Fengates Road V229812 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) 6,7,8 &9 Service users goal plans are reflected in individual care plans and are based on assessment. Service users are consulted on and participate in aspects of life in the home and are supported to make decisions in their daily lives. Service users are supported to take risks as part of an independent lifestyle EVIDENCE: Service users have a comprehensive care plan in place, which is based on assessment. Plans included histories and clear goal plans that are based on health, social and emotional needs. One service user confirmed that she participates in her meeting, which take place every six months. Service users and keyworkers sign individual plans. Service user meetings are held quarterly and are documented and service user satisfaction questionnaires have been implemented. Care plans provided information on likes, dislikes and individual preferences. Service users were observed to make choices in their daily lives. One service user was invited into the kitchen and was asked to make a preference for breakfast and individual preferences were respected in offering a bath or having a shower. One service user spends her money at the shop and was given the opportunity to purchase goods of her choice. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 10 Comprehensive risk assessments were implemented and included household activities, finance and emotional risks. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 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 standard(s) 11, 12, 13,14,15,16 &17 The home is able to demonstrate that service users are supported to maintain and develop social, emotional communication and independent living skills. Service users have access to community facilities and are supported with undertaking appropriate leisure activities. Links are maintained with family and friends and there was evidence that independence and choice was being promoted. Meal times were flexible and a choice of meals was available. EVIDENCE: Service users have the opportunity to participate in daily life skills. Individual plans were in place to address communication skills, daily living skills and emotional needs. Service users have opportunities to undertake household tasks such as cleaning and vacuuming and two service users like to cook. Opportunities were available to go shopping, using the library and going to the local post office. Some service users attend local colleges and are undertaking a range of courses and one service user has supported employment. Other recreational activities included music, sensory sessions, trampolening and attendance at a local daycentres. A range of leisure activities was available Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 12 including visiting the cinema and pub. Two service users had returned from a holiday and another service user was away on holiday in Wales. Service users were supported to maintain links with families and friends and one service user said that she maintained contact with her relative by phone. Menus are organised on a weekly basis involving service users. Service users and staff were observed talking and interacting with each other and discussing the menu followed by a shopping trip. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 The home is able to demonstrate that the health and emotional care needs are met. Service users receive personal support in the way prefer. Service users are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Care plans clearly reflect individual’s health care needs and identify preferences. Privacy for service users was maintained and two care plans sampled indicated that service users have access to a local GP, community nurses and referrals were made to opticians, dentist and health screen checks. Guidelines were available for supporting service users who experienced emotional difficulties. A service user confirmed that she is supported in the bathroom, which she prefers. Due to the holidays service users were being offered the opportunity of having a lie in and were having breakfast at a preferred time. Medication records were sampled and were adequately maintained. As required medication protocols were in place and there was evidence that administration of medication training for staff was taking place . Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 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 standard(s) 22 &23 The home provides an accessible complaints procedure. Policies and procedures were in place to ensure that service users are protected from abuse. EVIDENCE: A comprehensive complaints policy is in place which is accessible to service users in picture format. A protection of vulnerable adults policy is in place making reference to whistle blowing. However the home is required to obtain an updated copy of the local authority protection of vulnerable adults policy to protect the safety of service users and to provide staff with necessary guidance. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 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 standard(s) 24,25,26,27,28 &30 Service users live in a comfortable and well-furnished home. One minor item was identified that requires action. Service users have comfortable, spacious bedrooms that promote their lifestyles. Adequate toilets and bathrooms were in place, which offer privacy. The home is clean and hygienic. EVIDENCE: The home is well maintained and creates a warm, homely feel. The home is close to local shops and amenities. Furniture and fittings were adequate. Service users live in single bedrooms that were furnished appropriately. Bedrooms were bright and personalised to individual preferences. Ventilation and lighting was adequate. Bathrooms and toilets meet the needs of the service users and were clean and hygienic. A bath panel in the upstairs bathroom was worn and had rough surfaces. This should be replaced to ensure the comfort and safety of service users. There was a comfortable lounge and separate dining room and the kitchen was maintained to a good standard. A record of regular maintenance was sampled Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 16 and food was stored appropriately and fridge temperatures were recorded daily. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 &36 The staffing levels were adequate to meet the needs of service users. Staff were supported to undertake training and development to ensure they are competent to undertake their job. Regular formal supervision is implemented and appropriate checks are completed. The home needs to ensure that all documents are available on personnel files to ensure that service users are protected by the homes recruitment policies and procedures. EVIDENCE: Staff personnel files were sampled and found to contain job descriptions and it was clear that staff were guided through the homes policies and procedures. There was evidence that staff receive induction. Some staff were being supported in completing National Vocational Qualifications. Training records were sampled and mandatory training was up to date including fire safety, food hygiene and first aid. Some staff have undertaken training in mental health awareness, autism and communication, which was relevant to the service users being supported. The staff rota was sampled and levels were adequate to meet the needs of the service users. A requirement was made that all staff files should contain evidence of appropriate recruitment checks including two references, as these were absent Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 18 on one file sampled. This is required to ensure service users are supported and protected by the homes recruitment policy and practices. Staff supervision records were sampled and it was clear that formal supervision takes place every two months and records were maintained. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 19 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 home is managed in an open and inclusive atmosphere. The home implements quality assurance systems seeking views from service users. Staff receive regular formal supervision. Policies were implemented that protect the health, welfare and safety of service users. The manager needs to submit an application for registration to the Commission for Social Care Inspection for registration. EVIDENCE: The manager has management experience and is completing the Registered Managers Award. However a requirement was made at the last inspection that the manager submits an application for registration with the Commission for Social Care Inspection and this is still outstanding. This has now been made an immediate requirement. The home was observed to run in an open, positive atmosphere and the manager communicated a clear sense of direction and leadership. The home has implemented a quality assurance system by providing service user questionnaires. Visits and reports from the responsible individual takes Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 20 place monthly to check the conduct of the home and the quality of care provided. Policies and procedures were sampled and it was clear that safe working practices are adhered to. Health and safety, manual handling, control of harmful substances and food hood hygiene legislation was adhered to. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 21 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fengates Road (5) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 3 x x 3 x H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 22 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 37 Regulation 8 (1)(a) Requirement The home manager must sumit an application for registration to the Commission for Social Care Inspection. The home manager must otain an updated copy of the local authority protection of vulnerable adult procedure to ensure the safety and well being of service users The bath side panel must be replaced in the upstairs bathroom to ensure that the comfort and safety of service users is protected. The home manager must ensure that two references are available on all staff personnel files to ensure that service users are protected by the homes recruitment policy and practices. Timescale for action immediate 25/7/05 1 month 25/8/05 2. 23 13(6) 3. 24 23(2)(b) 2 months 25/8/05 4. 34 19(1)(b) schedule 2 immediate 25/7/05 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 H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 23 Fengates Road (5) 1. Fengates Road (5) H58 S13510 5 Fengates Road V229812 250705 Stage 4.doc Version 1.30 Page 24 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. 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