Inspection on 07/06/05 for Hersham Road (20)

This inspection was carried out on 7th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hersham Road (20) 08/05/07

Hersham Road (20) 20/04/06

Hersham Road (20) 10/11/05

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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Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ Lead Inspector Vera Bulbeck Unannounced 07 June 2005 10:45 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. 20 Hersham Road Version 1.10 Page 3 SERVICE INFORMATION Name of service 20 Hersham Road Address 20 Hersham Road Walton-on-Thames Surrey KT12 1JZ 01932 269171 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) Welmede Housing Association Ltd To be confirmed Care home only (PC) 8 Category(ies) of Learning disability (LD), 6 registration, with number Learning disability over 65 years of age (LD(E)), of places 2 Physical disability over 65 years of age (PD(E)), 1 Physical disability (PD), 1 20 Hersham Road Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the 6 service users in the category LD, up to 1 may also fall within category 2 Of the 2 service users in category LD(E), up to 1 may also fall within the category PD(E). 3 The age range of the persons accommodated in the home will be: SIX (6) 36-65 YEARS and two (2) 65 YEARS AND OVER Date of last inspection 13 January 2005 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. 20 Hersham Road Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The aim of the unannounced inspection was to provide an opportunity to meet and speak with residents and staff and to follow up the requirements and recommendations made as a result of the last inspection. It was disappointing to note that requirements had been carried over more than once since 15th July 2004. It is highly recommended these requirements and recommendations be attended to immediately. It will be necessary to review both inspection reports for 2005-06, undertaken by the Commission, to obtain a full understanding of the extent to which the home meets the 43 standards of The National Minimum Standards for Younger Adults. This inspection identified that further development of the home is required before it will fully meet the requirements of the Care Homes Regulations 2001 further details are outlined in the main body of the report. Service users in this home are called residents and therefore the word resident will be used in the remainder of this report. Residents were seen to be well supported with their personal care needs and to be relaxed and confident with staff on duty. The management and staff were helpful and supportive of the inspection process. What the service does well: What has improved since the last inspection? 20 Hersham Road Version 1.10 Page 6 A new manager has been appointed to the home since 6th June 2005. There are a number of areas of concern to be addressed. However, the manager is confident she will be able to meet the challenge. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 20 Hersham Road Version 1.10 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 20 Hersham Road Version 1.10 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) 1 and 5. The home has a detailed and informative statement of purpose and service users’ guide. These documents, together with the home’s procedure of carrying out detailed assessments and offering a well-structured series of visits prior to admission, enable residents and prospective residents to make an informed choice about admission to the home. The individual written contracts need to be revised to ensure that all relevant information is available. EVIDENCE: The homes statement of purpose needs to be updated and should include relevant information as detailed in The Care Homes Regulations 2001, Schedule 1. Prospective residents would find it difficult to understand the homes service user guide, and therefore it needs to be in a format for all the residents to be able to read. Two care plans were sampled and it was noted that care plans are in need of updating and require more detailed information. The manager informed the inspector that care plans are in the process of being changed. For example the use of bed rails must be clearly documented on the residents care plan and should be signed by the resident/doctor or relative. 20 Hersham Road Version 1.10 Page 9 Contracts were in place but need to be updated to include room numbers and should include extra expenses for example purchasing E45 cream. 20 Hersham Road Version 1.10 Page 10 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, 9 and 10. The service users’ individual plans are in the process of being changed and should be clear and comprehensive including details of needs and goals. They also need to incorporate known or indicated preferences with in depth risk assessments. EVIDENCE: Plans do not appear to reflect some of the areas of need; they are not up to date and have not been regularly reviewed. Entries made gave little indication of the actual care given. Risk assessments had not been completed on residents. A key worker system is in place and staff have the responsibility of helping residents achieve everyday goals, such as holidays or going shopping. It was noted by the inspector on one of the residents daily record notes had not been completed for some days. Staff in a Key worker role helps residents to arrange social events of their choice also hospital and GP appointments. The inspector spoke with a number of residents and was able to communicate. The staff have a good understanding of the needs of residents and are able to communicate by means of sign and body language with some residents. 20 Hersham Road Version 1.10 Page 11 20 Hersham Road Version 1.10 Page 12 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) 13, 15 and 17. The residents have opportunities for personal development, to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Meals are well balanced and varied. Systems are in place to ensure that resident’s rights are respected. EVIDENCE: There was evidence to support that residents are encouraged to be as independent as possible and observation confirmed the staff talk to them and provide support when required. Residents enjoy a number of activities, these include, shopping and swimming. Three or four residents go to church every Sunday, and every month the local vicar visits the home for a service, which all residents attend. Four residents and three members of staff are going on a cruise holiday to Spain for one week and three cabins have been booked. Some residents prefer to go out on day trips. 20 Hersham Road Version 1.10 Page 13 Lunch was observed by the inspector to be served by a member of staff, there was choice of salad or pasta. Some residents are involved with the preparation of the meals. 20 Hersham Road Version 1.10 Page 14 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) 18 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. Policies and practices are in place for the administration and management of medications. However all staff administering medication require training. EVIDENCE: Staff administers medication, there are no residents who are able to self medicate. It was noted in some resident’s bedrooms sudacream and E45 cream was left for staff to use on residents when required. Medication must be stored a locked facility. It was also noted that all staff administer rectal diazepam, training must be obtained by the community nurse and evidence of staff undertaking this training must be held on file. The inspector was informed two residents have difficulty swallowing tablets and one resident has her tablet on a spoonful of jam. This practice must cease immediately, the inspector advised the home to contact the G.P for the medication to be prescribed in liquid form. The manager stated she had already contacted the G.P and he will be changing the medication. The manager also stated that the medication system is being changed to the nomad system and is currently waiting for the pharmacist to visit. 20 Hersham Road Version 1.10 Page 15 Medication procedures must be followed and staff training must be undertaken on all staff that administers medication. 20 Hersham Road Version 1.10 Page 16 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. All required policies and procedures are in place however, these need to be updated to ensure that service users feel their views will be listened to. Policies are in place to protect service users from abuse and neglect but lack of staff training and recruitment procedures are placing them at possible risk of harm and abuse. EVIDENCE: Records indicated there had been no formal complaints received by the home, since the last inspection. The organisation Welmede Housing Association Ltd have its own adult protection policy and procedure and a copy of Surrey’s multi agency vulnerable adult procedure was available in the home. Some staff have received training in this area and all new staff cover the training as part of their induction. However, a member of staff who has been working in the home for 8 years was not aware of the whistle blowing policy. All staff must have regular updates to the protection of vulnerable adults procedure training. Staff need to be aware of the policies and procedures and must be aware of the whistle blowing policy. 20 Hersham Road Version 1.10 Page 17 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, 26 and 29. 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 homely and welcoming, and each bedroom was nicely decorated and personalised. A number of aids were available in the home. However, there were some areas that require attention. Bedroom furniture for example wardrobes and televisions needs to be reviewed with regard to being secured to the wall to ensure the stability is sound. In the a bathroom on the first floor the tap needs a shower valve, and the toilet and bathroom on the ground floor the blind needs attention. All bathrooms, toilets and kitchen need paper towels. Automatic door closures should be fitted on all bedroom doors to eliminate doors being wedged open. It was also noted in the accident book a resident had fallen out of bed and had been wedged between the wall and the bed. On 20 Hersham Road Version 1.10 Page 18 examination of the bed, which was found to move even with the locks on the wheels of the bed. The bed wheels need attention. All hoovers should be stored in an appropriate area and not left in hallways, particularly fire escape routes. At the time of the inspection it was also noted that all residents should be offered a key to their bedrooms. If residents are unable to hold a key this should be clearly documented in their care plan. The garden path at the back of the house has a number of loose slabs, which could be a potential hazard to residents and staff. 20 Hersham Road Version 1.10 Page 19 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) 31, 34, 35 and 36. The recruitment of staff procedures and staff records were not available, therefore do not provide the safeguards to offer protection to residents living in the home. EVIDENCE: The management of the home needs to develop a training programme which would help to identify staff training needs at a glance. There are a number of staff that require further training. Recruitment records were not available, the manager informed the inspector that she had only been in post for one day and had not been given the key to the filing cabinet. Access to staff records have been a previous requirement, staff records must be available for inspection purposes. The manager informed the inspector that supervision on staff had commenced. However, staff when spoken to stated that supervision had been arranged but cancelled and some were not aware what supervision was. Supervision needs to be undertaken on a regular basis at least six times a year. The registered manager stated that supervision training had been organised for herself and 20 Hersham Road Version 1.10 Page 20 the deputy manager to attend in September 2005. Appraisals need to be undertaken on a yearly basis. 20 Hersham Road Version 1.10 Page 21 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) 37, 41 and 42. The leadership, guidance and direction to staff need to improve, to ensure residents receive consistent quality care. The shortfalls in the result of some practices do not promote and safeguard the health, safety and welfare of the residents living in the home. A new manager is in post and aims to meet the challenge of the home meeting all the National Minimum Standards for Younger Adults. EVIDENCE: It was disappointing to note that a number of the previous requirements had not been met, from the last inspection, and will be carried over to the next inspection. At the time of the inspection the inspector discussed the need for the management of the home to hold regular meetings with the residents, and minutes of the meeting to be held on file. Regular visit by the responsible person are undertaken monthly. 20 Hersham Road Version 1.10 Page 22 Policies and procedures were observed and some were found to be in need of updating, the last reviewed date was 2002. A number of records were examined these include: • The accident book needs to comply with the health and safety regulations. All entries need to be numbered, to enable a trail of the recorded accident. The staff are currently using the same form to record accidents and incidents. • Fire records need to be reviewed to ensure the homes risk assessment is up to date and includes the whole of the premises. The fire alarm system must be checked on a weekly basis. The homes policy on undertaking a fire drill states should be three monthly, the last recorded fire drill was dated 27/02/05. In the kitchen there were opened packets of breakfast cereals on the shelf. All dried food must be stored in a sealed plastic container with a lid once opened. Cleaning materials were seen under the sink in an unlocked cupboard. All cleaning materials must be stored appropriately. This was an immediate requirement. In a residents bedroom there was a UVB florescent light without a cover, the inspector advised the home to contact an electrician for advise on the safety of the light. The inspector noted a number of portable heaters in resident’s bedrooms with trailing wires; these are a health and safety hazard. The inspector was informed that the central heating breaks down on a regular basis. It is highly recommended the home contact an appropriate person to inspect the system. Automatic door closures need to be fitted to a number of doors to eliminate doors being wedged open. Bedroom doors need to be numbered for fire safety precautions, and a list of the bedrooms must be held beside the fire panel. The shed in the garden must be kept locked at all times. On the day of inspection it was found to contain equipment and cement. Another shed was found to contain pads and wheelchairs, which was found to be leaking badly. These items need to be removed immediately. The home has a double garage which currently houses the ex managers car which has been smashed up. The car needs to be removed. • • • • • • 20 Hersham Road Version 1.10 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x 3 x Standard No 11 12 13 14 15 20 Hersham Road x x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x x 2 3 3 Version 1.10 Page 24 16 17 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 2 x 20 Hersham Road Version 1.10 Page 25 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 6, 41 Regulation Requirement Timescale for action 22.07.05 14, 15, 13 The home must ensure that the care plan and documentation system includes the following: · A comprehensive assessment of needs covering all areas of health, personal and social care needs (including specialist needs i.e. care of epilepsy, behaviour management) · Comprehensive risk assessments · Restrictions on choice based on assessment · Details of each individual need/risk identified · Goal/objective for each need/risk · Actions to be taken for each identified need/risk to ensure the goals are met · Daily report writing to evidence that identified needs and goals are being met and identified actions carried out · Documented evidence of the regular review of care plans Evidence that the service user is aware of and agrees the contents of the care plan(timescale 15.05.05 not Version 1.10 20 Hersham Road Page 26 met) 2. 34 17 That Staff personnel files are organised in a fashion that makes them easily accessible (timescale 15.07.04 not met) The manager must maintain, in the care home, the records specified in Schedule 4 of The Care Homes Regulations 2001 and must ensure that these records are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home (timescale 13.01.05). The home revise and develop new contracts which contain all elements listed in Standard 5.2. New contracts to be issued to and signed by each resident or their representative and the Registered Manager Residents be offered keys to their bedrooms and the front door of the home unless otherwise indicated by individual, documented risk assessments. Where service users decline, this should be clearly documented in their file The provider fit approved closing devices to the identified bedroom fire doors to ensure that fire safety regulations are met whilst at the same time promoting service users’ freedom of movement. All medication must be stored in a lockable cupboard at all times. Staff to receive training by the community nurse on the use of rectal diazipam. All staff must have up to date training on the protection of vulnerable adults procedures. Records to be reviwed and kept Version 1.10 22/07/05 3. 34, 41 17 24.06.05 4. 5 5A 22/07/05 5. 16 12 22/07/05 6. 16,42 13 22/07/05 7. 20 13 07/06/05 8. 9. 23 41 13 17 22/07/05 01/07/05 Page 27 20 Hersham Road up to date. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 42 42 42 42 42 42 42 42 42 42 42 24 26 13 13 23 23 13 13 23 16 16 23 23 23 16 All cleaning materials, paint and cement must be stored in a locked facility at all times. Sheds to be kept locked at all times containing equipment. The UVB florescent light without a cover needs urgent attention. The central heating system needs to be checked and reviwed. All bedroom doors need to be numbered and a list to be held next to the fire panel. Paper hand towels are required in all toilets, bathrooms and kitchen. A fire risk assessment to be undertaken on the whole house. Equipment for example the hoover must be stored appropriatly All dried foods including cereals must be stored in a sealed plastic container. The testing of the fire alarm system to be checked on a weekly basis. The smashed up car in the garage to be removed. The garden path in the back garden needs attention. The wheels on a residents bed need attention. 07/06/05 07/06/05 10/06/05 22/07/05 01/07/05 22/07/05 22/07/05 10/06/05 07/06/05 07/06/05 01/07/05 22/07/05 01/07/05 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. Refer to Standard 26 Good Practice Recommendations To review the stability of furniture and fittings in residents bedrooms. 20 Hersham Road Version 1.10 Page 28 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 20 Hersham Road Version 1.10 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!