Inspection on 04/11/05 for Gubbins Lane

This inspection was carried out on 4th 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gubbins Lane 09/02/07

Gubbins Lane 13/09/05

Gubbins Lane 31/03/05

Gubbins Lane 22/02/05

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 Gubbins Lane 26 Gubbins Lane Harold Wood Romford Essex RM3 0QA Lead Inspector Harbinder Ghir Unannounced Inspection 4th November 2005 01:00 Gubbins Lane DS0000027853.V263509.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 Gubbins Lane DS0000027853.V263509.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. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gubbins Lane Address 26 Gubbins Lane Harold Wood Romford Essex RM3 0QA 01708 384525 01708 384525 sara@outlook.org.uk 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) Outlook Care Ms Sara Petley Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2005 Brief Description of the Service: 26 Gubbins Lane is a care home registered to provide care, support and accommodation to 6 adults of both sexes aged between 18-65 with physical and learning disabilities. The home is a one level purpose built property and gardens with car parking facilities to the front of the building. The home is located in a residential area of Harold Wood, close to shops, public transport and the M25, A127 and the A12. The home employs staff, working a roster, which gives 24-hour cover. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Harbinder Ghir, Regulatory Inspector, undertook this unannounced inspection on the 4th November 2005 and was at the premises from 11.35am to 1.50pm. The visit included talking with residents and staff. Some judgements about quality of life within the home were taken from direct conversation with staff and observation. In addition a tour of the premises was undertaken and some records were looked at. During the inspection 5 residents were at the home. Due to the profound level of learning disabilities, residents at the home were not able to verbally communicate to the inspector. 1 Requirement was made at the time of the last inspection, the timescale has not yet been reached, so has been re-stated with a new timescale. Further information about the unmet requirement can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. This was the second statutory inspection for 2005/6, and across the two visits all core standards have been assessed. What the service does well: Residents’ wishes in the event of death are established through liaison with their representatives and are handled with respect and as the individual would wish. Policies, procedures and staff training are provided that protect residents from abuse. Staff supervision is regarded as priority by the home and staff are regularly supervised. Residents are protected by the home’s recruitment policy and practices. Staff training is comprehensive with training needs regularly updated. The home has a registered manager in post that recognises residents’ needs and manages the home well. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. The home listens to its residents and relatives through regular quality assurance meetings and actions any issues through these meetings and the homes annual business plan. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 6 Regular maintenance checks are completed by the home ensuring the health, safety and welfare of residents and staff are promoted and protected. 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. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users needs are fully assessed prior to admission. Standards 1, 3, 4, 5 were not tested on this visit. However evidence from the last inspection was that: The home’s Statement of Purpose and Service User Guide are excellent. They provide service users and prospective service users with the information they need to make a decision about moving into the home. Service users’ needs are fully assessed. Service users have access to specialist services if they need them. EVIDENCE: The home has a good pre-admission assessment form. Pre-admission assessments are completed by the manager, who assures potential residents and their representatives that their needs can be met by the home. Assessments are also acquired from local authority social services for local authority funded residents. Standards 1, 3, 4, 5 were not specifically tested on this visit, as there were no outstanding requirements in relation to standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that: There is a clear and consistent care planning system in place, which provided staff with the information they needed to meet the needs of residents. Residents are supported to make active choices and decisions throughout their daily living and areas of risk are assessed. Information about service users is kept confidential. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to standards 6, 7, 8, 9, 10. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 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 the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that: Residents are provided with the support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life; enjoy a range of leisure activities and a varied and nutritional diet. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to standards 11, 12, 13, 14, 15, 16, 17. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 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 the following standard(s): 21 Residents’ wishes in the event of death are established through liaison with their representatives and are handled with respect and as the individual would wish. Standards 18, 19, 20 were not tested on this visit. However evidence from the last inspection was that: Personal, physical and emotional healthcare is provided that meets residents’ needs and wishes. Residents are protected by clear and comprehensive arrangements for the administration of medication. EVIDENCE: To establish residents’ wishes in the event of death the home completes paper work to establish the wishes of residents with their relatives, family or representatives. 4 completed forms were seen which were kept in residents’ care plan file to ensure all staff are aware and can deal with the situation as the individual would wish. The home has a comprehensive policy and procedure on dying and death. Standards 18, 19, 20 were not specifically tested on this visit, as there were no outstanding requirements in relation to standards. At the time of the last Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 12 inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 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 the following standard(s): 23 Policies, procedures and staff training were provided that protected residents from abuse. Standard 22 was not tested on this visit. However evidence from the last inspection was that: The home provides a satisfactory complaints system and residents feel that their views are listened to and acted upon. EVIDENCE: Policies and procedures regarding the abuse of vulnerable adults were provided. Records seen identified all staff received training on adult abuse and this was also incorporated into the induction programme. Feedback from staff demonstrated that they were aware of the policies and understood what action to take in the event of an allegation or suspicion of abuse. Standard 22 was not specifically tested on this visit, as there were no outstanding requirements in relation to the standard. At the time of the last inspection, the outcome for the standard was assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that: Residents’ benefited from living in a safe, well-maintained and clean environment. Décor, furnishings and fittings that are of a good standard and provide a homely and pleasant living environment enhance their comfort. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to standards 24, 25, 26, 27, 28, 29, 30. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36 Staff were aware of their and other’s job roles and responsibilities, providing clarity of roles to residents. The home needs to review its staffing levels at peak times to ensure the needs of all residents are met. Recruitment processes are robust and ensure the protection of residents living at the home. The staff group receive adequate training to meet the needs of residents. Staff receive supervision on a regular basis Standards 32, and 35 were not tested on this visit. However evidence from the last inspection was that: Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. The staff group receive adequate training to meet the needs of residents. EVIDENCE: The GSCC Code of Conduct is covered in the induction training programme and copies are available in the home. Discussions with staff indicated that they were aware of their roles and responsibilities. A requirement was set at the previous inspection that the registered manager must ensure that, in regards to the number of residents and their assessed level of needs, appropriate numbers of persons are working at the care home at peak evening hours to ensure the needs of all residents are met effectively. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 16 Currently the staff team consist of permanent and agency staff. Agency staff are used due to sickness absence, maternity and annual leave. Staff morale is very high. However the duty rota identified staff shortages during evening times, as two members of staff attend to those residents with complex needs whilst one member of staff is left to attend to 4 other residents which does not ensure all the needs of residents at this time are being met adequately as residents are left waiting for long periods of time. Staff spoken to also highlighted staffing shortages during this time. They informed that the evenings are very difficult for staff. The duty rota seen provided adequate numbers of staff at all other times. This above requirement has not been actioned, so has been restated as requirement 1. On inspecting the homes recruitment procedure, four staff files were viewed during the inspection. The files were complete with all relevant checks required by the regulations. The files included a comprehensive completed application form, two good references, medical check, copies of ID, signed contract of terms and conditions, job description and a photograph of the applicant. Staff records seen identified members of staff were being supervised regularly. A supervision programme for all members of staff was in place highlighting booked supervision dates. The manager informed that they are trying to supervise all staff on a monthly basis. Standards 32 and 35 were not specifically tested on this visit, as there were no outstanding requirements in relation to the standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Residents’ benefit from an experienced manager who recognises their needs and manages the home well. The manager has a clear vision for the home, which she has effectively communicated to residents, relatives and staff. The systems for Service User consultation are good with evidence that Service User views are sought via their representatives and acted on. The welfare of staff and service users are promoted by the homes policies and procedures at all times. Standard 41 was not tested on this visit. However evidence from the last inspection was that residents are safeguarded by the home’s record keeping policies. EVIDENCE: The manager has many years experience of working with this service user group and is in the process of completing the Registered Managers Award. Staff spoken to at the home stated the home was well run and they were well supported by the manager. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 18 The quality assurance system includes seeking the views of residents’ relatives and representatives by the home holding 3 monthly meetings as residents are not able to verbally communicate their views. The minutes included ways in which issues raised will be actioned by the management team. Records of quality assurance surveys were also seen, which are sent out yearly to residents’ relatives and representatives. The results of surveys are published in the annual business plan and discussed with staff and relatives and representatives. Stakeholder evaluation surveys are also given to Stakeholders on a yearly basis. Reports regarding monthly visits in accordance with Regulation 26 visits have been received by CSCI, which are comprehensive and consider the quality of the service for which they are responsible. The manager and staff take overall responsibility for ensuring relevant maintenance checks are carried out throughout the home. It is clear from the records seen that all relevant legislation is complied with and reportable incidents are reported to the appropriate authorities. Fire signs and safety posters are evident throughout the home. All members of staff have health and safety training as part of the induction process. Standard 41 was not specifically tested on this visit, as there were no outstanding requirements in relation to the standard. At the time of the last inspection, the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 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 X X X X X X x 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 3 X 2 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gubbins Lane Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000027853.V263509.R01.S.doc Version 5.0 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 YA33 Regulation 18(a) Requirement The registered manager must ensure that, in regards to the number of residents and their assessed level of needs, appropriate numbers of persons are working at the care home at peak evening hours to ensure the needs of all residents are met effectively. (Previous timescale of 13/10/05 not met) Timescale for action 13/01/05 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 Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Gubbins Lane DS0000027853.V263509.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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