Inspection on 08/11/05 for Gloucester Road (22)

This inspection was carried out on 8th November 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

Gloucester Road (22) 07/01/09

Gloucester Road (22) 20/12/07

Gloucester Road (22) 12/04/05

Gloucester Road (22) 09/11/04

Gloucester Road (22) 18/05/04

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

CARE HOME ADULTS 18-65 Gloucester Road (22) 22 Gloucester Road Kingston Upon Thames Surrey KT1 3SJ Lead Inspector Michael Williams Unannounced Inspection 8th November 2005 15:00 Gloucester Road (22) DS0000013392.V264071.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 Gloucester Road (22) DS0000013392.V264071.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. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gloucester Road (22) Address 22 Gloucester Road Kingston Upon Thames Surrey KT1 3SJ 020 8547 0610 020 8546 3832 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) www.together-uk.org Together Working for Wellbeing Mr Philip Desmond Wright Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th April 2005 Brief Description of the Service: 22 Gloucester Road is a large, detached property situated on the outskirts of Kingston-upon-Thames. Town centre facilities are within easy reach and the home is conveniently situated for access to public transport networks. The property is owned by the Local Authority, the Royal Borough of Kingston, but the project is managed by the Mental After Care Association. The home has a contract with a local Primary Care Trust. The local primary care trust also contributes to the funding of the project.The home offers six bedrooms on the ground floor of the property and a further ten bedrooms on the first floor. The home has a large garden to the rear, mostly laid to lawn with a range of mature trees and shrubs. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced inspection undertaken in the Autumn of 2005 and was the second statutory inspection for this year. The home was full, 16 service users in all, and some service users assisted in the inspection process. This is a long established care home specialising in the care of people with enduring mental health problems and does so in a caring and pleasant atmosphere. It is managed by “Together” (formerly ‘MACA’), a national charity specialising in this form of care and support. In April achieved good standards in all those areas assessed at that time and this inspection was to confirm standard are still being met and to confirm requirements have been addressed. What the service does well: 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. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 6 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 Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 7 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): The key standard in this section was assessed as met in the previous inspection and there was no indication that it is not still being met. EVIDENCE: The following conclusion were drawn in April 2005; Assessments and Care Plans are in place for each service. Multidisciplinary assessment are undertaken and include the service user’s contribution; risk assessments are in place for issues such as self-medication, travelling, handling chemicals (cleaning), dealing with money, cooking and so forth. So the prospective service user will be assured that their needs are properly assessed prior to admission to ensure they can be met in this care home. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 8 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): The key standards in this section were assessed as met in the previous inspection and there was no indication that they are not still being met. EVIDENCE: The following conclusion were drawn in April 2005; Care planning that involves the service user is in place. Arrangements have been made to ensure service user consultation takes place in an informal but regular and methodical manner. Most service users are quite active and enjoy a range of activities including some that pose some degree of risk and this is being suitably assessed by staff in collaboration with the service user. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 9 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): The key standards in this section were assessed as met in the previous inspection and there was no indication that they are not still being met. EVIDENCE: The following conclusion were drawn in April 2005; The home encourages community participation and helps service users engage in leisure activities of their choice. The home is very welcoming and personal relationships are supported. The dining room is homely and congenial setting but would be improved by removing the freezer and filing cabinet. The meals are reported to be satisfactory. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 10 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): The key standards in this section were assessed as met in the previous inspection and there was no indication that they are not still being met. EVIDENCE: The following conclusion were drawn in April 2005; Personal and health care is provided according to service users’ individual needs. Clinical support for specific health care is provided by the General Practitioner service, by District Nurses and by the psychiatric multi-disciplinary teams as well as other specialist services such as the continence advisor chiropody, sight and hearing services. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 11 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 Complaints: The home has a clear and simple procedure for dealing with complaints so service users’ are confident their concerns will be dealt with promptly and effectively. Protection: The home has written policies and procedures about the protection of service users and their property; this includes procedures for passing on concerns to the relevant authorities including the CSCI. So this will ensure vulnerable service users are safeguarded from abuse. EVIDENCE: Complaints procedures are in place and records of any complaints are maintained. The local authority’s guidance on the protection of vulnerable adults is known to staff. The organisation ‘Together’ has in place a whistleblowing procedure to ensure staff know how to report abuses should they occur. No complaints have been recorded since the previous inspection in April and none were raised during the inspection. As before, this inspection also included interviews with staff and the person in charge. These interviews were all very positive and without criticism of the home. The managing organisation ‘Together’ assists in the process of recruitment including police checks, identity and qualification checks and references. In respect of money held by the organisation, it was again confirmed by staff that most service users make their own arrangements for dealing with their finances including a personal bank account. One service is supported by the Court of Protection and arrangements are in place to ensure she is protected from financial abuse including an audit trail of her cash when handled by staff. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 12 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 30 Premises: The layout of the home and the manner in which it is being maintained are satisfactory so this means it is a safe and comfortable environment for the service users. There were however a number of matters requiring attention and they are outlined below. Hygiene: Housekeeping is well organised in this home so the premises are being kept clean, hygienic and free from offensive odours … and systems are in pace to control the spread of infection. EVIDENCE: The inspector toured the premises observing matters such as general firesafety matters; the use of cleaning materials and how they are stored, the quality of floor coverings, furnishings and fittings and the general décor of the home. The home is in good state of repair and furniture and fittings are satisfactory The home was clean and tidy and free of offensive odours. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 13 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): 32 34 35 Staff levels: The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this ensures that their needs are being met. Recruitment procedures in this home are sound and so will ensure service users are appropriately supported and protected. Training: The home has a staff induction, training, support and supervision regime in place so this will ensure they are competent in their jobs. EVIDENCE: As an existing care home staffing levels are to be no less that proscribed by the previous registering authority. On the day of inspection it was noted that for 16 service users there were 2 care support workers plus the person in charge; ancillary staff were also on duty including a cleaner and a cook. A part-time gardener/handyperson is to be employed in due course. This is within the minimum staffing levels required. Staff records were checked and the staff and the person in charge were interviewed to confirm inspection findings. The organisation has a national reputation for providing a comprehensive training programme including induction training to ‘TOPPS’ standards (a nationally accepted induction Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 14 process) as well as ongoing training and support and regular supervision so this appears to be a well managed home with a professional staff team. The person in charge asserts that all staff have had a police check and a sample of CRB (police) checks were examined to confirm this. Other recruitment processes are in place including application forms, references, health and qualification checks and interviews. The overall process appears sound and so it is clear service users are in safe hands and certainly service users say they are satisfied with this home. In respect of equality issues, it is evident that an open and unbiased approach is taken when recruiting staff so that minority and other special needs groups are not disadvantaged by the recruitment process. The home employs a staff from a range of cultural and ethnic minority backgrounds and employs a number of staff who reflect the culture and background of the service users. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 42 The two positive inspections in 2005 indicate that service users are benefiting from a well run home. Those safety matters requiring attention in the previous inspection have been addressed so service users can be assured that their health, safety and wellbeing are being promoted. EVIDENCE: Standards met in so far as this is clearly a well managed home backed by a competent organisation and the home is run in a safe and comfortable manner. The service users endorsed this judgement. A tour of the premises failed to identify any hazards on this occasion. The staff team is supported by a multidisciplinary psychiatric team to ensure the health, mental and physical, is promoted. That some service users have moved ion to more independent accommodation indicates the home is promoting service users’ wellbeing and is commended for its good work. Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 16 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 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gloucester Road (22) Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000013392.V264071.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations Gloucester Road (22) DS0000013392.V264071.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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