Inspection on 20/02/07 for High Street (31)

This inspection was carried out on 20th February 2007.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

High Street (31) 10/11/05

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 Unannounced Inspection 20th February 2007 10:00 High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 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.V327545.R01.S.doc Version 5.2 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.V327545.R01.S.doc Version 5.2 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.V327545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 18-65 YEARS 10th November 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 service provides care for up to three service users two with learning disabilities and one with a mental disorder excluding learning disability or dementia. Each service user has their own furnished bedroom and there is a communal lounge and small dining room. 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. Charges for the service range from £1213 - £1625 per week. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was part of the key inspection process and commenced at 10.10 am and ended at 2.15pm. This visit was completed by Mrs C Clarke regulation inspector. Isaac Tagoe Registered Manager who was representing the establishment assisted throughout the site visit. The inspection of 31 High Street took place over a period of 4 ½hrs during which samples of; care assessments, care plans, a tour of the premises and staff records were inspected. All of the key inspection standards for Younger Adults were assessed. Three service user surveys were received by the CSCI and comments have been included in this report. Three members of staff and one service user were interviewed during the site visit and pre-inspection documentation was used to plan the site visit. The Commission for Social Care Inspection would like to extend thanks to the service users, management and staff of 31 High Street for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The personal information of all service users must be treated appropriately respecting their confidentiality. As such, information contained in service users High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 6 contracts must not contain information relating to other service users. This will ensure that service users can be confident their personal information is managed in a confidential manner. The home is advised to request a dietician check the menu to ensure that it provides a balanced and healthy variety of food and drink. In order to protect the safety of service users, all medicines must be administered directly from the original labeled container to the service user and not placed into any secondary container for later administration by any other carer. Safeguarding adults training must be provided for all staff and an up to date copy of the local authority safeguarding procedures be obtained A number of environmental improvements were required at the time of this site visit including repairs and maintenance to kitchen flooring; an external wall; and redecoration and repair of some other internal areas. The home must be kept clean at all times and the planned maintenance and redecoration carried out. The registered manager agreed to contact the maintenance person to ensure that exposed wiring in a service user’s bedroom was made safe and that this would be undertaken on the day of the inspection. This will ensure that service users have a safe, clean and well maintained home to live in. Recruitment records must contain a full employment history to ensure that service users safety is promoted and protected. 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. The summary of this inspection report can be made available in other formats on request. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 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.V327545.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 5 were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to their admission to the home to ensure that the service meets their needs. Each service user is issued with a contract outlining their terms and conditions. EVIDENCE: There are comprehensive assessment records in place detailing the complex needs of service users. There are also assessment records completed by the Local Authority on file. The newest service user to move into the home made a number of visits to the service prior to admission including an overnight stay. Assessment records contain information on the ethnicity and diversity of service users and their religious and cultural needs are identified. Each of the service users has a contract in picture format outlining the terms and conditions of their stay. There is also an agreement on file from the local authority regarding the purchase of residential care services for each individual. One of the individual’s contracts sampled contained the name of a different service user compromising the confidentiality and accuracy of the information contained within the record. Please see requirements section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect the changing needs of service users and any personal aspirations or goals. Service users are encouraged to be independent taking into account any risks and assistance is given where appropriate. EVIDENCE: Each service user has a set of protocols in place identifying their goals and achievements. Risk assessments are undertaken for each individual and care plans reflect how their independence is to be gained taking each risk area into account. All care plans had been regularly reviewed with input from service users, care managers, staff and relatives. The registered manager has stated that they do not have advocacy involvement for any of the service users. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15 and 17 were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in a number of individually assessed activities; have their rights respected and appropriate relationships with family are enjoyed. Service users are offered a varied diet and enjoy their meals. EVIDENCE: There is a structured programme of activities taking into account the individual likes and dislikes of the service users. Two of the service users were out at day care during the site visit and the other service user was looking forward to attending cookery classes in the afternoon. One of the service users likes to attend a drama group on a Tuesday evening and has been rehearsing for a show. Two of the service users attend college. Family visit the home regularly and one of the service users goes to stay with his parents for overnight stays once per fortnight. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 11 Service users take a packed lunch when they are out of the home during the day. The home is advised to request a dietician check the menu to ensure that it provides a balanced and healthy variety of food and drink. There are no special diets required for service users. One of the service users does have fortified drinks and his weight is regularly monitored. The registered manager has stated that his family are happy with his present weight. Please see recommendations section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20 were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is provided observing privacy, dignity and promotes the service users independence. Medication policies, procedures and practice in place protect service users. EVIDENCE: During the site visit one of the service users was visiting his GP for a check up he was assisted by one of the members of staff. Service users are assisted with their personal care needs observing their right to privacy and independence. Records showed that service users regularly attend dental check ups and appointments with other health care professionals. There was one gap on one of the medication administration charts and the member of staff concerned agreed that it was an error. The registered manager audits the medication records. There are recording systems in place for returning medicines to the pharmacist. Signatures of staff who are trained High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 13 to administer medication is held in the office. The medication is kept in a locked cabinet secured to the wall outside of the office. There are no controlled drugs within the home. One service users medication is removed from the Monitored dosage system and put into a dossett box by the staff in the home for transfer to the day centre. In order to protect the safety of service users, all medicines must be administered directly from the original labeled container to the service user and not placed into any secondary container for later administration by any other carer. Please see requirements section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel that their views are listened to and they know how to make a complaint. The service has policies and procedures in place for both complaints and safeguarding adults for staff to follow in the event of any concerns, complaints or allegations protecting service users from abuse, neglect or self harm. EVIDENCE: There have been no complaints or safeguarding matters since the last inspection visit. The registered manager has stated that he will obtain a copy of the most recent and up to date local authority multi-agency procedures. There are policies and procedures in place for both safeguarding and making a complaint. The registered manager has stated that he has applied for updated training from the local authority for safeguarding and is awaiting a place on the next available programme. He stated that information will then be cascaded down to staff to ensure that they are fully aware of the safeguarding adults procedures. Please see the requirements section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were inspected during this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the environment within the home are needed to ensure that service users live is a safe, well maintained and clean home. EVIDENCE: The registered manager has stated that the home is to be completely redecorated and that service users have been involved in choosing the new colours for their rooms. The architraving surrounding the door in the lounge needs to be repaired and repainted. The manager confirmed that the lounge suite is to be replaced. The flooring in the kitchen was not clean and there were areas where the flooring was not sealed. Skirting boards, doors and appliance switches were also in need of cleaning. It is recommended that the home devise a cleaning rota to ensure that all parts of the home are kept clean at all times. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 16 The wall in the rear garden with a major crack down it must receive attention to ensure safety. The wall by the gateway is included in the current maintenance plan for the building and the registered manager has stated that the home is to purchase a new gate. The exposed wire in one of the service users bedrooms must be encased to ensure his safety. The registered manager agreed to contact the maintenance person to ensure that this was undertaken on the day of the inspection. The registered manager stated that the plugs in the adaptor in the lounge behind the television had been checked as safe for use and that he would ensure that they were kept behind the TV cabinet. One of the radiators in a service users bedroom was very hot and the registered manager stated that a risk assessment is in place. It was reported by the manager that a radiator cover is not suitable for this service user. The registered manager has stated that the service will review the current arrangements to ensure the safety of service users. Please see the requirements section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 were inspected during this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are supported by a competent, trained and a well supervised staff team, however the recruitment practice needs to be improved to ensure the safety and protection of service users. EVIDENCE: There was one member of staff on duty plus the manager. The manager stated that the service is one member of staff short of its full compliment. Most staff are employed on a part time basis. One member of staff stated that she had worked for the home for five years and liked working with the service users and other members of staff. There is an induction programme for new staff in place. The staff recruitment files included copies of the questionnaires used to interview staff with an equal opportunities approach. Criminal record bureau checks were in place for all records sampled. Medical questionnaires for each member of staff were kept in the staff file. Copies of passports, birth certificates and residents permits were held. Application forms did not contain High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 18 a full employment history and one member of staff did not have the required number of references. Two staff have achieved NVQ Level 2 in Care. Three staff are to enrol with the local college for NVQ training. Staff have undertaken infection control and health and safety training. There is a comprehensive training programme in place. Supervision is undertaken on a one to one basis and is currently up to date. Please see requirements section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were inspected during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users and there is a quality assurance process to ensure that the views of service users are heard and any changes to improve the service are made. Health and safety policies and practices in place ensure the well being of service users, staff and visitors to the home. EVIDENCE: The registered manager has completed the National Vocational Qualification Level 4 Registered Managers award and is a member of the Chartered Management Institute. The service undertakes an internal quality assurance audit and the home is awaiting the outcome of the results from head office. The manager has stated that monthly monitoring visits have been completed as required by regulation High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 20 26 however there was no evidence to substantiate this. The manager stated that copies of the reports are held at the head office of the service and copies would be sent to the home. It is recommended that the accident and incident records be kept in accordance with data protection guidelines as described in the accident book to improve the confidentiality of information held. Health and safety checks are undertaken and records kept within the home. Please see recommendations section of this report. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 22 NO 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 YA4 Regulation 5 (1) (b) Requirement Timescale for action 31/03/07 2. YA20 13 (2) 3. YA23 13 (6) 4. YA24 23 (2) (b) Service user contracts must record details pertaining to the individual concerned and be signed by them where appropriate. In order to protect the safety of 31/03/07 service users, all medicines must be administered directly from the original labeled container to the service user and not placed into any secondary container for later administration by any other carer. The registered person must 30/06/07 ensure that all staff are aware of the procedures to be undertaken in the event of an allegation of abuse. The lounge, hallways, and 31/07/07 bedrooms must be painted and decorated as planned and the architraving surrounding the door in the lounge must be repaired and repainted. The flooring in the kitchen must be replaced and the garden walls must be maintained to ensure the safety of service users and visitors to the home. High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 23 5. YA30 23 (2) (d) All parts of the home must be kept clean at all times. 31/03/07 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 YA30 Good Practice Recommendations It is recommended that the home devise a cleaning rota to ensure that all parts of the home are kept clean at all times. It is recommended that the home keep the accident and incident forms in accordance with current guidelines as set out in the accident book. 2. YA42 High Street (31) DS0000013486.V327545.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V327545.R01.S.doc Version 5.2 Page 25 - 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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