Inspection on 10/11/05 for High Street (31)

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

High Street (31) 20/02/07

High Street (31) 23/09/05

High Street (31) 04/01/05

High Street (31) 28/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

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 High Street (31) 31 High Street Horsell Woking Surrey GU21 4UR Lead Inspector Cathy Clarke Announced Inspection 10th November 2005 10:00 High Street (31) DS0000013486.V270576.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 High Street (31) DS0000013486.V270576.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. High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service High Street (31) Address 31 High Street Horsell Woking Surrey GU21 4UR 01483 757995 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) Quest Haven Ltd Mr Isaac Tagoe Care Home 3 Category(ies) of Learning disability (2), Mental disorder, registration, with number excluding learning disability or dementia (1) of places High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 18-65 YEARS 23rd September 2005 Date of last inspection Brief Description of the Service: 31 High Street is a detached bungalow situated in a residential area of Horsell close to shops and facilities. The home provides services for two young adults with a learning disability and one young adult with a mental disorder. Each service user has their own furnished bedroom. A medium sized garden area surrounds the bungalow with car parking facilities to the front of the property. The service is close to Woking town centre where good transport links are available to the surrounding areas. High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Cathy Clarke, Regulation Inspector, carried out this inspection Mr. Isaac Tagoe Registered Manager and Mr. Tom Tagoe Director of Quest Haven were present as the representatives for the establishment. A full tour of the premises took place and documents inspected included care plans, policies and procedures. One service user was spoken to during the inspection. Comments have been included in the report received from Service users, a Senior Care Manager, A Care Manager from the Learning Disabilities team, General Practitioner, and relatives/carers. Two members of care staff were interviewed as part of the inspection process. The inspector would like to thank the staff and service user for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The service user records have been reviewed and updated since the last inspection and are much easier to follow. The kitchen has been completely refurbished and a new fridge/freezer, dishwasher and washing machine. The garden has been maintained and the registered manager confirmed that the service is to explore the provision of a gardener. The flashings have been removed from the garden and the service provider has contacted the double-glazing company to repair the flashings to the front High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 6 of the property. A revised timescale for completion has been given to allow for this work to be done under its terms and conditions of guarantee. Plugs have been removed from the adapter behind the television. The staffing structure within the home has improved and the registered manager is to receive regular assistance from the head office administrator. 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. High Street (31) DS0000013486.V270576.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 High Street (31) DS0000013486.V270576.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): 5 The homes statement of purpose and service user guide has been developed in order to provide prospective service users with all of the information necessary to make an informed choice of home in which to live. Contracts have been developed. EVIDENCE: Each service user has a contract on file outlining the terms and conditions of their stay at the home. The contracts are in pictorial format and are signed by the service user and the registered manager. High Street (31) DS0000013486.V270576.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): 7 Care plans and risk assessments are in place. Service user files have been radically improved and information held within them is easy to locate and follow. EVIDENCE: Care plans sampled were comprehensive with protocols, which include a description of the short and long-term goals that service users are working towards achieving. Service users have confirmed in their comment cards that they have a care plan. Care plan reviews have been conducted between the local authority care management service and the provider. Staff have confirmed that they find the care plans give clarity to their work. High Street (31) DS0000013486.V270576.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): 16,17 Service users are encouraged to be as independent as possible taking into account their safety at all times. Menu plans sampled showed a variety of choices. EVIDENCE: One of the service users was in at the time of inspection and he likes to take an active part in the inspection process. One of the service users gets the local bus to the day centre. The registered manager confirmed that because it is dark in the evening staff would pick her up. The service takes her to college because there is no direct route. Most of the service users go shopping by themselves and attend a club in a local centre in the evening on a Wednesday. Service users have stated that going to work, going on outings/holidays or out to listen to music or the pub is what is good about living in the home. One of the service users wishes to move to another home owned by Quest Haven in the same area where she would live with other female service users. Care management have stated in her care plan that she is to be assisted with the move by an allocated care manager. High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 11 Menu plans are developed over a four-week period. None of the service users were in at lunchtime during the inspection. One of the service users likes to prepare his packed lunch. High Street (31) DS0000013486.V270576.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): 18,20 Personal and healthcare support and assistance is provided for service users taking into account their need for independence, privacy and choice. Medication policies and procedures are in place. EVIDENCE: Care Managers have stated that staff have a clear understanding of the needs of service users. Relatives and carers have stated that they are satisfied with the overall care provided. The service user in the home on the day of inspection indicated that he was happy with the care provided. All of the service users are assisted where required with personal care but independence is promoted and encouraged. Personal care is provided in private either in the service users room or in the bathroom. One of the service users self medicates under supervision of staff, a locked cabinet for medication storage is in her room. Medication stored within the home was checked as correct and medication administration records were correctly completed. The home has recently received a Pharmacy visit and all recommendations have been met. Staff have been trained to administer medication. High Street (31) DS0000013486.V270576.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): Policies and Procedures are in place for complaints and the protection of vulnerable adults. EVIDENCE: There has been one complaint since the last inspection and this has been responded to formally using the homes complaints procedure. There have been no vulnerable adult investigations since the last inspection and staff have confirmed that they have attended Protection of Vulnerable adults training. High Street (31) DS0000013486.V270576.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): 24,28,30 Many improvements have been made to the environment both internally and externally. EVIDENCE: The home is clean and tidy and the kitchen has been totally refurbished since the last inspection with a new fridge/freezer, washing machine and dishwasher having been purchased and installed. The new kitchen gives a bright and airy feel to the home. The number of plugs in the adaptor behind the television in the lounge has been reduced. The garden has been maintained; lawns cut, weeds eradicated and the registered manager has stated that the service is to look into the provision of a gardener for the property. Broken flashings have been removed from the rear garden, and the service has contacted the double-glazing company regarding replacement to the front of the property. The flashings are still within their guarantee period and the service has assured the inspector that this will be maintained under those terms and conditions. Please see requirements section of this report. High Street (31) DS0000013486.V270576.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): 32,34,35,36 Staffing within the home has improved. Service users are supported and protected by robust recruitment policies and procedures. EVIDENCE: Staffing has increased since the last inspection ensuring that there are sufficient staff on duty to meet the needs of service users. Recruitment files sampled during the inspection contained the following: application forms, copy of passport, national insurance number, POVA first check, two references, the registered manager confirmed that they sometimes obtain three references. Criminal record bureau checks have been conducted on all staff working at the home. Supervision notes were contained within staff files and training questionnaires are completed following any training. Gaps in knowledge are picked up during supervision. Training certificates included care and control of medicines, introduction to moving and handling, protection of vulnerable adults, epilepsy and the use of rectal diazepam, in-house fire training and Non abusive, psychological, and physical intervention training, which the manager informed the inspector is approved by the Home Office and the British institute of learning disabilities. Five staff hold a current first aid certificate. Two staff have qualified to level 2 NVQ Care and all others are registered to complete the award. High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 16 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 Systems in place for the effective management of the home have been improved. The home has a clear set of policies and procedures in place. There are health and safety policies and procedures in place. EVIDENCE: Information within service users files is now in order and more accessible. Assistance with record keeping, filing, and general administration is to be provided by the Head Office administrator to enable the smooth running of the service. The registered manager has completed his level 4 Registered Managers award. Systems within the office have been improved since the last inspection and there was marked improvement in the organisation of the service. Surveys are conducted with service users, family, and health care professionals and these are sent to the Head Office and feedback is given to service users and the registered manager. High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 17 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 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 High Street (31) Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000013486.V270576.R01.S.doc Version 5.0 Page 18 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 YA24 Regulation 23 (2) (b) Requirement The flashing board, which has become detached from the front of the property, must be replaced. An extended timescale has been agreed. Timescale for action 31/03/06 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 High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 19 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 High Street (31) DS0000013486.V270576.R01.S.doc Version 5.0 Page 20 - 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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