Inspection on 10/11/05 for Hersham Road (20)

This inspection was carried out on 10th 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hersham Road (20) 08/05/07

Hersham Road (20) 20/04/06

Hersham Road (20) 07/06/05

Hersham Road (20) 13/01/05

Hersham Road (20) 15/07/04

Hersham Road (20) 12/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hersham Road (20) 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ Lead Inspector Vera Bulbeck Announced Inspection 10th November 2005 10:00 Hersham Road (20) DS0000013464.V254309.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 Hersham Road (20) DS0000013464.V254309.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. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hersham Road (20) Address 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ 01932 269171 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) Welmede Housing Association Ltd To be confirmed Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2), Physical disability (1), of places Physical disability over 65 years of age (1) Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Of the 6 service users in the category LD, up to 1 may also fall within category PD. Of the 2 service users in category LD(E), up to 1 may also fall within the category PD(E). The age range of the persons accommodated in the home will be: SIX (6) 36-65 YEARS and two (2) 65 YEARS AND OVER One (1) of the service users in category LD(DE) To include one (1) named service user over the age of 65 years with dementia. 7th June 2005 Date of last inspection Brief Description of the Service: 20 Hersham Road is an adapted large house situated on a busy main road in a residential area, which is within walking distance of all community facilities of Walton On Thames. Service provision is for up to eight people with learning disabilities, some of who have physical disabilities in addition to their primary condition of a learning disability. The service affords all single bedroom accommodation on the ground and first floor with the third floor designated for staff use only. Wheelchair users are confined to the ground floor as provision of a lift is not available. There is a spacious combined lounge/dining room overlooking a furnished patio and a large, attractive well maintained enclosed garden. Residents have access to the home’s vehicle, which is equipped for transporting wheelchair users. The service is owned by Welmede Housing Association Limited and staffed by employees of the North Surrey Primary Care Trust through a support agreement between the Trust and Welmede Housing Association. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken by the Commission for Social Care Inspection for the year April 2005 to March 2006. For details of how each standard was met please refer to the main body of the report. It will be necessary to review both inspection reports for 2005-06 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Younger Adults. The inspection was announced, which meant that visitors, staff and residents were aware of the inspection prior to it commencing. The inspector had the opportunity to speak with a number of residents who live at the home. They were all very complimentary about the home and spoke affectionately of the registered manager and staff. Vera Bulbeck, Lead Inspector for the service, carried out the inspection, which was for a period of five hours and thirty minutes. Mrs Amanda Salih, Manager was present. The home is registered for eight places. There are currently eight residents living in the home. A full tour of the premises was undertaken. Three care plans were observed and three staff files were inspected. Four members of staff were spoken with during the inspection as well as all the residents. The inspector received three relatives comment cards, which were all very positive and spoke highly of the care provided in the home. A comment card was also received from the G.P who visits the home on a regular basis; the comments were of satisfaction by the doctor. The staff was observed to be courteous and the atmosphere within the home was relaxed and friendly. The inspector wishes to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. What the service does well: The manager and staff have made real progress in the improvement of the physical environment for the residents. The manager has been in post a short time and has made a great improvement to the home. Staff commented they feel supported and valued. Routines in the home are flexible and residents make choices about how they wish to spend their time. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 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. Hersham Road (20) DS0000013464.V254309.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 Hersham Road (20) DS0000013464.V254309.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): 3 and 5. Residents’ needs are fully assessed prior to admission and all residents have a written contract. EVIDENCE: The manager and staff were able to demonstrate that the home had the capacity to meet the assessed needs of younger adults requiring personal care as stated in the statement of purpose. A key worker system is in place and staff has the responsibility of helping residents achieve everyday goals. Staff in a Key worker role; help residents to arrange social events of their choice as well as supporting residents to make hospital and GP appointments. All residents have received licence agreements, containing all the relevant information required. Hersham Road (20) DS0000013464.V254309.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): 6 and 9. The residents’ individual plans are clear and comprehensive and include details of needs and goals. They also incorporate known or indicated preferences and in depth risk assessments. EVIDENCE: The residents’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences with in depth risk assessments. Risk assessments had been completed on residents who are able to undertake a number of daily living tasks. It was noted that a number of care plans have been up dated and some are in the process of being up dated. It was clear from observation that residents are encouraged by staff to undertake various jobs around the house this includes loading the dishwasher, laying the table, helping in the kitchen and generally tidying their bedrooms. Hersham Road (20) DS0000013464.V254309.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): 12, 13, 16 and 17. The residents have opportunities to take part in appropriate activities both within the home and in the local community. EVIDENCE: All residents have a full and varied activity programme. Examination of the home’s records confirmed a high degree of personal empowerment and choices in resident’s daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. Residents are encouraged to pursue individual interests and hobbies. Staff attempts to maintain links with resident’s families. The home has maintained some good family links. There are no restrictions in terms of visiting times. There was evidence in the care plans that residents are supported to be as independent as possible, and are free to make decisions where possible. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 11 Two residents attend Adult Education activity, and the majority of residents had access to a range of appropriate leisure opportunities including the day centre in accordance with individual preferences. It was disappointing to hear that one resident likes to swim, and the local swimming pool telephoned the home to say the hoist was not working, and there was no given date when this might be repaired. Mealtimes were a social occasion and the meal served on the day of inspection was well balanced and nourishing. All staff handling food must have a certificate in food handling which the majority of staff have. Those staff members who do not have the certificate have been booked onto a course, and in the meantime are not handling food. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. Personal care and healthcare support and assistance is planned and was seen to be provided where needed, in a respectful and sensitive manner. Sound policies and practices are in place for the administration and management of medication. EVIDENCE: Care plans showed that Opticians, GPs, Psychologists, Audiologists, and Care Managers had seen residents for regular check ups and review visits. Monthly reports show evidence of health appointments, activities and financial transactions. Medication cabinets are kept in each room, there are no residents who are able to self medicate. Medication administration records were correctly completed. Signatures are audited daily to ensure medication is correctly administered. There are no controlled drugs and a separate book records medication coming into the home and being returned to the pharmacy. A General Practitioner has commented that staff are aware of residents needs. However, staff need to be aware that keys should not be left in locked cabinets in residents bedrooms with medication stored. Hersham Road (20) DS0000013464.V254309.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): 22 and 23. All required policies and procedures are in place to ensure that residents feel their views will be listened to. Policies are in place to protect residents from abuse and neglect. EVIDENCE: Staff spoken to, stated that they had undertaken training in the protection of vulnerable adults and would report any concerns they had to their line manager. If they had concerns about their line manager, they would be reported to the area manager. Staff said they would be willing and able to report any concerns and “would go to any level to protect residents”. The majority of staff working in the home has undertaken training on the protection of vulnerable people. Hersham Road (20) DS0000013464.V254309.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): 24, 26, 28 and 30. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were found to be clean and hygienic all staff to be congratulated on the cleanliness of the home. Each resident has their own bedroom and these had been made personal with pictures and posters, televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size. It was noted that one resident was without a headboard; the inspector was informed this was on order. It is pleasing to see that each room is individually decorated and residents are supported to choose the colour schemes to suit their preferences. There is a large lounge, which is open plan to a dining room. French doors from the lounge open onto an enclosed garden to the back of the house; the garden is nicely laid and well maintained. However it was disappointing that a requirement was made at the previous inspection for the pathway slabs to be re-laid as they were found to be uneven and extremely Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 15 dangerous for residents. However, this had not been attended to and will be carried forward to this inspection report with a short timescale for action. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 16 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): 34, 35 and 36. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual residents at the home. Staffing is kept under review and provided to meet the needs of the residents at all times. Action must be taken to improve the recruitment procedures. EVIDENCE: It was pleasing to note that staff have a good understanding of the residents needs, are respectful and have a good rapport with the residents. Staff recruitment files need to be updated and should contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. A number of documents were missing from staff files. It was noted that the current manager does not have access to staff files at the present time, until the manager is registered by Commission for Social Care Inspection (CSCI). All staff must have a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. It was noted that there were no records available for one member of staff who had commenced work in July 2005. Another member of staff had completed a CRB but it was a standard check instead of an enhanced. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. The management of the home has produced a training programme, to enable management to identify when staff require up dates to Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 17 their training. A number of training courses have been undertaken and all new staff receive an induction programme, which is covered over several weeks. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 18 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): 40, 41 and 42. Resident’s benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known. EVIDENCE: The home has an effective quality audit monitoring system in place. The service manager completes a regular monthly regulation 26 notification visit and the report is well documented. A number of records observed on the day of inspection were found to be well documented and kept up to date. An emergency plan is in the process of being completed. This document must be contained in the fire record folder. The management of the home needs to up date a number of their policies and procedures and these should be specific to 20 Hersham Road. Residents meetings are to be undertaken from the end of November. Staff meetings are undertaken every two months and it was noted that two Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 19 residents attended this meeting. The inspector advised the manager to produce an action plan to enable residents and staff to be clear about what action will be taken. The home has been provided with a computer since the previous inspection. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 20 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 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 3 X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hersham Road (20) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X 2 3 3 X DS0000013464.V254309.R01.S.doc Version 5.0 Page 21 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 2 Standard 24 42 Regulation YA23 YA23 Requirement The garden path in the back garden needs attention. (Timescale 22/07/05 not met). The central heating system needs to be checked and reviewed. (Timescale of 22/07/05 not met). Staff files to be maintained and relevant documents as detailed in Schedule 2 to be available in the home for inspection purposes. Policies and Procedures to be reviewed and should be specific to 20 Hersham Road. Timescale for action 09/12/05 02/12/05 3 34 YA19 09/12/05 4 40 YA17 09/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA24 Good Practice Recommendations The keys must not be left in the door of resident’s lockable cabinet when medication or valuables are inside. To ensure a resident has a headboard for his bed. Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office 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 Hersham Road (20) DS0000013464.V254309.R01.S.doc Version 5.0 Page 23 - 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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