Inspection on 27/09/07 for Gonville Road (33)

This inspection was carried out on 27th September 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gonville Road (33) 25/09/08

Gonville Road (33) 07/09/06

Gonville Road (33) 15/11/05

Gonville Road (33) 13/05/05

Gonville Road (33) 24/11/04

Gonville Road (33) 13/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Gonville Road (33) Bovell`s Lodge 33 Gonville Road Thornton Heath Surrey CR7 6DE Lead Inspector Jon Fry Key Unannounced Inspection 27th September 2007 10:15 Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gonville Road (33) Address Bovell`s Lodge 33 Gonville Road Thornton Heath Surrey CR7 6DE 020 8683 4802 T/F 020 8683 4802 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) Wilfred Bovell Barbara Ellaine Bovell Mr W Bovell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users who have additional mental health needs to be accommodated until such time as the needs of the service users can no longer be met or until such time as the placements cease. 7th September 2006 Date of last inspection Brief Description of the Service: Bovells Lodge is a small care home for up to three adults who have a learning disability. The home is situated in a residential area of Thornton Heath with good access to local transport links and amenities. The premises consist of three goodsized single bedrooms on the first floor, communal lounge, open plan dining / kitchen area, laundry and office. There is a garden to the rear of the home. The registered owner is also the manager and is very involved with the day to day running of the service. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent two hours at the home. We spoke to one person who uses the service as well as the manager and a staff member. Records and documents looked at included care plans, staff files and Health and Safety records. A completed survey was received from one person who lives at the home. The home completed an Annual Quality Assurance Assessment (AQAA) to tell us about the service provided, how it makes sure of good outcomes for the people using it and any planned developments. What the service does well: What has improved since the last inspection? What they could do better: Criminal Records Bureau (CRB) checks must be obtained for all new care staff. Staff files must contain important information such as references and copies of identification documents. Better Health and Safety records need to be kept around checks for Fire Safety and hot water temperatures. Care plans could be improved and reviewed more regularly. Please contact the provider for advice of actions taken in response to this Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Written information is made available about the service provided. Assessments are carried out before people come to live at the home. EVIDENCE: A Statement of Purpose and Users Guide provide information about the service. This includes how to make a complaint and contact details for the CSCI. We have recommended that the guide is made available in different formats such as large print or pictures. We saw that copies of Local Authority assessments are kept on file and these look at the support and assistance people need. This information is then used in care planning. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans need more detail and be reviewed at least every six months. EVIDENCE: We looked at one care plan in place for a person using the service. This gives basic information on their support needs but to be developed to look at all areas of their life and the assistance they require. Future plans and goals also need to be included so that the necessary support can be provided to achieve these. An annual review has been taking place but the home must make sure that the care plan is reviewed at least every six months with records kept. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 10 There are risk assessments to guide staff on how to protect individuals from potential harm. We saw that these need to be reviewed regularly and be included as part of the care planning process. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to attend appropriate activities within the home and in the local community. EVIDENCE: The person we spoke to said that they were involved in activities such as karate, pottery classes and going to evening clubs. They said they went to Church every week and recently had a ‘good’ holiday. “I get the things I like” was their comment about the food provided at the home. On the day we visited, we saw that they were able to get up at the time they wanted and were served a cooked breakfast. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to appropriate healthcare professionals. Health needs are monitored and appropriate action taken. Improvements have been made around managing medication. EVIDENCE: People who use the service have access to health professionals in the community including the GP, dentist and optician. Records are kept of health appointments and any actions required. We saw that a person currently using the service had been supported with their health needs by the service. We saw that medication is now managed well by the home and improvements have been made around record keeping. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A complaints procedure is in place for the home. The home’s policies, procedures and practices help to safeguard individuals from abuse. EVIDENCE: A person living at the home said that they knew who to speak to if they were not happy with something. A complaints procedure is available in the home. This has been formatted with symbols and pictures to make it more accessible to individuals. The manager said that there have been no complaints since the September 2006 inspection. There are appropriate policies and procedures in place regarding Safeguarding Adults. Staff have previously attended training on adult protection but the newest staff member will need to have this important training. We have recommended that the home accesses Local Authority training as it becomes available to make sure they are up to date with the procedures in use. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is decorated and furnished to a good standard and provides people with a homely and comfortable place to live. EVIDENCE: The home provides a family type environment for the people who live there. We saw that it is maintained to a good standard and the communal areas are comfortable and homely. We looked at one bedroom in use at the time of this visit. This was furnished to suit the individual and had been personalised. The home was clean and hygienic at the time of this inspection. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have satisfactory training opportunities. The recruitment process needs to be improved to make sure that appropriate checks are made. EVIDENCE: The owners are the main carers and people living there are supported to be part of a homely family type environment. Two additional part time staff are employed. We looked at the recruitment records for both members of staff. One new carer had been employed without a new Criminal Records Bureau (CRB) check being obtained. We saw that this person had already had a recent check with a previous employer but this does not excuse the home from having to apply for one. The file containing references and other required documentation also could not be found at the time of this visit. The file for the other member of staff was satisfactory and contained the necessary documentation. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 16 Files showed that one staff member has been on training such as Food Hygiene, First Aid and abuse awareness. The manager said that both care staff are due to start the NVQ Level Two qualification. We have made Requirements for both staff to be trained in Fire Safety (as highlighted at the last Fire Officers visit) and that any new staff have an induction that is to Skills for Care specification. Staff supervision still needs improvement to make sure that staff receive the formal support needed to help them do their jobs well. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the required experience and qualifications to run the home. Health and Safety is generally well managed to keep people safe although some improvements are still needed. EVIDENCE: The manager has over six years experience working with people with learning disabilities and has been running the home since it opened in 2003. He has completed the NVQ Level Four qualification in management and care. As seen at the September 2006 inspection, generally the procedures and records required are in place but they could be organised better. The manager Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 18 had trouble finding some of the documents we wanted to look at and it is recommended that the files are re-organised to make access easier. We looked at the Health and Safety records for the home. Regular checks are completed for areas such as gas and electrical safety, Legionella and fire equipment. The home still needs to make sure that recorded weekly checks are carried out for hot water temperatures of baths and showers and for the tasting of fire alarm points. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 20 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 YA6 Regulation 15 Requirement People living at the home must each have an up to date plan of care that is based upon their assessed needs and identifies what support is required from staff. This will help to make sure that the needs of people living at the home are being fully addressed. (Previous timescale of 31/08/07 not fully met) Each care plan must be reviewed at least every six months. 2. YA9 13 (4) Risk assessments must be reviewed regularly or as individual needs change. This will help to make sure that peoples health and welfare is being protected. To ensure that individual’s welfare is safeguarded, all care staff must have received training in the Protection of Vulnerable Adults. The home must obtain new CRB disclosures for any care staff employed to work there. DS0000028514.V351955.R01.S.doc Timescale for action 31/12/07 31/12/07 3. YA23 13 (6) 31/01/08 4. YA34 19 (1) 31/10/07 Gonville Road (33) Version 5.2 Page 21 All other documentation as required by Schedule 3 of the Care Homes Regulations 2001 must be kept on file. This will ensure that people living at the home are protected by the recruitment procedures in use. To make sure that staff are appropriately trained, all staff must have training in Fire Safety and the use of the fire fighting equipment kept at the home. All new care staff must receive a documented induction that is to Skills for Care specification. 6. YA36 18 (2) To make sure that staff are appropriately supervised, all members of care staff must have formal documented supervision at least six times per year (prorata for part-time staff). (Previous timescale of 31/07/07 not fully met) 7. YA42 13 (4) Weekly recorded checks must be kept of fire alarm tests and the hot water temperatures of baths and showers. This is to ensure the health and welfare of people living at the home. 31/10/07 31/12/07 5. YA35 18 (1) 31/01/08 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 Good Practice Recommendations DS0000028514.V351955.R01.S.doc Version 5.2 Page 22 Gonville Road (33) 1. 2. 3. Standard YA1 YA23 YA41 The user guide for the home should be made available in other formats such as large print or pictures. The owners should access Local Authority training around Safeguarding Adults as it becomes available. The home should adopt a better filing system so that records are more easily accessible when needed. Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gonville Road (33) DS0000028514.V351955.R01.S.doc Version 5.2 Page 24 - 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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