Inspection on 23/08/05 for Greens (The)

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Greens (The) 10/05/07

Greens (The) 10/10/05

Greens (The) 03/08/04

Greens (The) 27/04/04

Greens (The) 20/01/04

Similar services:

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Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Greens (The) 388 Chessington Road West Ewell Epsom KT19 9EG Lead Inspector John Chivers Unannounced 23 August 2005 12.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Greens (The) Address 388 Chessington Road, West Ewell, Epsom, Surrey, KT19 9EG 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) 020 8224 3313 Mr Navaratnam Pakthyiendra Mrs Sharmini Pakthyiendra CRH Care Home 3 Category(ies) of LD Learning disability, 3 registration, with number LD(E) Learning dis - over 65, 1 of places Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be 30 - 65 YEARS although one person may be over the age of 65 and fall within the category LD(E) Date of last inspection 03 August 2004 Brief Description of the Service: The home is registered to accommodate a maximum of three residents of either gender all of whom have learning disabilities. The registered age range of the residents accommodated is thirty to sixty five years, although registered provision is also made for one resident aged over sixty five years. The home is privately owned and registered to Mr and Mrs Pakthyiendra. The home is a detached property set in a residential area off a main road and is close to local facilities and amenities. The home provides a caring and supportive service in a homely and comfortable environment. The home is decorated and furnished to a very good standard and has a large well maintained garden. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was undertaken on 23rd August 05. The duration of the inspection was 4 hours. As part of the inspection process limited discussion/communication was held with three residents. One member of staff was formally interviewed and discussion was held with the home’s manager. A range of policies, procedures and records were examined in addition to scrutiny of the resident’s files and a sample of staff personnel files. A tour of the premises was included in the inspection. The findings of the inspection were positive with observed evidence of good care practice provided by experienced staff. Resident’s were settled in their environment and had adequate degrees of autonomy and privacy. Residents indicated that they had no complaints about the service and that they were happy and well cared for in the home. Some records were well kept; however some shortfalls were evident. A range of policies and procedures were in place, though some needed expansion. It was noted that the home did not have a full Health & Safety policy statement. A comprehensive Health & Safety policy statement must be drawn up. Whilst a satisfactory standard of management was evident a total of eleven requirements and one recommendation are made. It must be noted that all of the resident’s have profound learning/communication difficulties and their views and opinions were difficult to ascertain with any accuracy. What the service does well: The home provides a very good standard of accommodation, which is homely and comfortable. The home maintains most of its statutory and non-statutory records in good order and keeps confidential information secure. The home has current utility test certificates and fire evacuation drills and alarm tests occur at the required frequency. The home works well with resident’s who have profound learning disabilities. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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 Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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) 2. The home ensures that needs assessments are undertaken prior to admission and are reviewed as appropriate. EVIDENCE: Written needs assessments had been prepared on all three residents prior to admission into the home. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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 and 9. The home has regard for maintaining residents care plans; however it is important that all care plans are reviewed. Residents take risks consistent to their assessed level of ability. EVIDENCE: Written care plans were held regarding all three residents. There was evidence of care plans being reviewed in all but one case, which hadn’t yet been reviewed for the current year. The manager stated that some residents had been without an allocated care manager for some time and this had hampered the reviewing process. This difficulty is acknowledged; however it is important that the care plan is reviewed and a requirement will be made regarding this. The residents have profound learning disabilities and are therefore only permitted to take risks consistent with their individual level of ability. Written risk assessments were held with evidence of periodic review. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14. The home encourages residents to take part in activities within and outside the home. The home has regard for resident’s having contact with the local community and their relatives. EVIDENCE: Two of the residents attend day centres and one resident is provided for within the home. Resident’s activity sheets were available and progress reports from day centres were held in resident’s individual files. Resident’s have contact with relatives and friends and visits are recorded in resident’s daily notes and the home’s diary. Visits to local venues occur and residents attend church services. It was evidenced that one resident attends a local synagogue. The home provides a range of activities. The manager stated that all of the resident’s enjoy flower arranging, music therapy and aromatherapy. Resident’s have an annual holiday and are due to holiday at ‘Centre Parks’ in September of this year. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 11 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) 19 and 20. The home has regard for health and medical matters concerning the residents; however visits to the GP and other health care professionals need to be more easily accessed by recording visits in the health section of resident’s individual files. EVIDENCE: Health care and medical details are included in assessments and care plans. Resident’s health care is monitored and recorded in the resident’s daily notes. Visits to he GP and other health care professionals are recorded in the home’s diary and log book. It would be important to also record such visits, the reason for the visit and the outcome of the visit in the resident’s individual files. This would provide for quick and easier access to such details and would be helpful for the purposes of confirmation. A requirement will be made regarding this. The home has an internal policy and procedure regarding the administration of medication. It was evidenced that staff sign the policy. In addition the home holds written guidance from the Royal Pharmaceutical Society. The resident’s medication records were inspected. Recording was clear and evidenced no gaps. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 12 Medication is stored in a lockable metal cabinet, which has provision for ‘controlled’ drugs; however currently no residents have been prescribed with such medication. Old or discarded medication is returned to the Pharmacy for disposal and a record stamped by the Pharmacy was available. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has regard for the protection of its residents and is committed to staff attending training in this area. The home needs to include additional details in its complaints procedures and obtain a book or suitable form in which to record any complaints received. EVIDENCE: The home has a written complaint procedure. The procedure is detailed; however it needs to be expanded consistent with Standard 22.4 of the National Minimum Standards for Care Home’s for Younger Adults to include that all complaints will be responded to within 28 days. The home also had a pictorial complaint procedure for the residents. This procedure is descriptive, although it needs to include the contact address and telephone number of the CSCI Surrey Area Office. The home does not currently have a book of form to record any complaints that may be received. Requirements will be made regarding this and the areas identified above. The manager stated that no complaints have been received. Due to the residents profound communication difficulties it was not possible to accurately ascertain their views regarding complaints; however they were observed to be settled, relaxed and content in their environment. The home has an internal policy and procedure regarding the Protection of Vulnerable Adults. In addition the home held the Surrey County Council MultiAgency Adult Protection procedures. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 14 It was evidenced that staff are due to attend training in the Protection of Vulnerable Adults on 6th September 05. It was noted that the manager had not received the Surrey County Council Multi-Agency training in the Protection of Vulnerable Adults. It is important that such training is arranged. A requirement will be made regarding this. The resident’s personal finances were inspected. The cash held was consistent with the balance entered in the resident’s individual cashbooks. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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 and 30. The home is maintained in good order throughout and has regard for providing a secure, comfortable and homely environment. EVIDENCE: The home is a detached property situated of a main road. Local facilities and amenities are close by. The property is attractive and the exterior is well maintained. The rear garden area is spacious and well kept. No safety hazards were evident in the garden area. The interior of the home was decorated and furnished to a very good standard. All communal areas and the resident’s bedrooms were homely and comfortable. The resident’s bedrooms had been personalised by their occupants. It was noted that two of the residents had large ‘free standing’ electric fans in their bedrooms. It would be important for the home to prepare written risk assessments regarding the use of the fans. A requirement under Standard 42 of this report will be made regarding this. Resident’s were observed to be ‘at ease’ in their bedrooms and the communal areas within the home. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 16 The kitchen was modern, spacious and well equipped. Toilet and bathing facilities were of a good standard and afforded privacy. Laundry facilities were satisfactory and COSHH items were securely stored in this area. All external doors in the home are electronically alarmed. The home has an ‘infection control’ policy; however this needs to be expended consistent with Standard 30.5 and 30.7 of the National Minimum Standards for Care Homes for Younger Adults. A requirement will be made regarding this. Standards of cleanliness and hygiene were high throughout the home. With the exception of the ‘free standing’ electric fans no potential safety hazards were evident. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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) 34 and 35. The home’s recruitment and vetting procedures are basically satisfactory; however one reference needs to be pursued regarding one member of staff and staff contracts/terms and conditions of employment need to be evidenced. Training opportunities have improved for staff. EVIDENCE: The home has a recruitment policy. Samples of staff files were inspected. The files contained varying amounts of information and in the main held: application forms, Criminal Record Bureau checks, Immigration and Home Office documentation, job descriptions, person specifications, copies of birth certificates, copies of training course certificates, photograph, and two written references, with the exception of one file which held one reference only. It was noted that copies of staff contracts/terms and conditions of employment were not available on staff files. A recommendation that copies are held on file will be made. The manager holds the NVQ level 4 (management) qualification, one member of staff holds NVQ level 3 and two staff are currently undertaking NVQ level 2 training. All staff attended medication administration training on 16th August 05 and staff are due to attend Adult Protection training in September 05. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 18 The manager stated that new staff have an ‘Induction Programme’; however there is no structured or written format for this. It is important that a written induction programme format is drawn up. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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) 39 and 42. The home has regard for quality assurance systems and whilst no serious Health & Safety hazards were evident, the home must prepare a written Health & Safety policy statement and liaise with the Environment Health Department regarding them visiting and inspecting the home. EVIDENCE: Questionnaires returned by resident’s relatives and professionals associated with the service were available. The questionnaires were for the year 2004 and the sample examined gave positive feedback regarding the service provided by the home. The manager stated that questionnaires for 2005 would be sent to the same parties in the near future. As the manager is also the registered service provider Regulation 26 visits are not necessary; however the manager stated that her husband who is also the registered provider would carry such visits regardless. This, in the inspectors view is good practice. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 20 The home has a ‘Hazard’ Identification document but does not have a written Health & Safety policy statement. It is essential that the home draws up such a statement in line with current health and safety legislation and keeps the statement available. The home did however have a Health & Safety ‘Law’ poster, which was prominently displayed. The home had a written fire risk assessment. The assessment was dated May 05. The fire officer visited the home on 9th August 04. The fire officer’s report stated that the home’s fire precautionary arrangements were satisfactory. There was documented evidence of fire evacuation drills occurring on a quarterly basis and fire alarm tests being undertaken weekly. Current utility systems test certificates for gas, electricity and portable electrical appliances were held. Hot water temperatures are taken and recorded on a weekly basis. The home has a ‘combination’ boiler and therefore legionella testing is not necessary. The manager stated that the Environmental Health Department (food hygiene) and (health & safety have never visited the home. If this is accurate it is important that the manager contact the Environmental Health Department and arrange that they inspect the home. The home’s accident report book was available. No accidents have been sustained by residents or staff. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greens (The) Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 23 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. 2. Standard .10 19 Regulation 15, (2) (b) 17 Requirement That the residents care plan referred to in report is reviewed. That inaddition to recording visits to the GP and other health care professionals in the diary and log they are also entered in the health section of residents files. The the contact address and telephone number of the CSCI Surrey Local Office is included in the residents pictorial complaint procedure. That a twenty eight day response time is included in the homes complaint procedure That the home introduces a book or form in which to record complaints. That the manager attends the Surrey County Council Multi-Agency training in the protection of Vulnerable Adults. That the home expand its infection control policy consistent with Standards 30.5 and 30.7 of the National Minimum Standards for Care Homes for Younger Adults. That the second reference for the member of staff referred to in Standard 34 of this report is located or a new one obtained. That the home introduce a formal written induction programme for staff. That the home draw up a written Health & Safety Policy statement consistent with current Health & Safety legislation. That the home contact the Environmental Health Department (food hygiene and health & safety) regarding an inspection at the home. That free standing fans are risk assessed. Timescale for action 1.10.05 1.10.05 3. 22.3 22, (2) 1.10.05 4. 5. 6. 7. 22.4 22.7 35 30. 5 & 7 22, (4) 22 18, (1) (c ) (i) 13, (4) (c ) 1.10.05 1.10.05 1.12.05 1.10.05 8. 34.2 19, Schedule 2 (5) 18, (1) (c ) (i) 12, (1) 1.10.05 9. 10. 35.3 42, 4 (i) 1.11.05 15.10.05 11. 24.11 & 42.2 (i) 42.6 12, (1) (a) 20.9.05 12. 13, 4 (c ) 20.9.05 Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 24 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 34. 6 Good Practice Recommendations That a copy of staff employment contracts/terms and conditions of employment are held on individulal staffs files. Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greens (The) HO9 H58 s13658 The Greens v231196 230805 stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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