CARE HOME ADULTS 18-65
High Street (31) 31 High Street Horsell Woking Surrey GU21 4UR Lead Inspector
Cathy Clarke Unannounced Inspection 23rd September 2005 10:30 High Street (31) DS0000013486.V255795.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.V255795.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.V255795.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.V255795.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 4th January 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.V255795.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 2 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 was present as the representative 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. 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? What they could do better:
Service users contracts must be reviewed and updated and outline the current terms and conditions of stay. High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 6 The Fridge/Freezer in the kitchen must be replaced and the kitchen refurbished as planned. The number of plugs in the adaptor behind the television in the lounge must be reduced. The garden to the rear of the property must be maintained, weeds eradicated and a more inviting environment developed. The flashing board, which has become detached from the front of the property must be replaced and removed from the rear garden. The staffing structure for the home must be improved to ensure that staff are available in addition to the registered manager. The storage of records within the office must be improved and records archived where necessary. Assistance with record keeping, filing, and general administration must be provided to enable the smooth running of the service. 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.V255795.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.V255795.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): 1,2,5 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. EVIDENCE: The statement of purpose and service user guide have both been reviewed and updated since the last inspection. Service users are assessed prior to admission at their home or placement. A contract was seen on a service users file but was last devised in March 2003. An updated version must be provided outlining the current terms and conditions of stay. Please see requirements section of this report. High Street (31) DS0000013486.V255795.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): 6,9 Care plans and risk assessments are in place. The collation of information in service users files needs to be easily accessible for the reader. EVIDENCE: Care plans and risk assessments are in place for each service user. The records are kept in a central file and a further file with historical information is kept in a locked cabinet. Service users are enabled to maintain an independent lifestyle and two of the service users work in the local community and attend day care facilities. High Street (31) DS0000013486.V255795.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): 12,13,15 Service users have opportunities for personal development, and to take part in activities within the local community. They are supported and enabled to develop close links with family and representatives. EVIDENCE: One of the service users who was very much part of the inspection process goes home on a regular basis. The other two service users were out at a local day care provision and work placement. Service users use the local facilities in Woking. Family and representatives can visit the home at any time. High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Personal and healthcare support and assistance is provided for service users taking into account their need for independence, privacy and choice. EVIDENCE: Service users records confirmed that they are seen on a regular basis by their GP. A Psychiatrist visits every two to three months. Dental and optical appointments are made every six months. One of the service users was feeling unwell at the time of inspection and the registered manager was monitoring his health needs. High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 12 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): These standards were not inspected during this inspection. EVIDENCE: High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 13 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 There are plans in place to refurbish the kitchen in the home and this will improve the environment of the home. The garden is to be maintained. EVIDENCE: The home is clean and tidy and the registered manager informed the inspector that the kitchen is to be completely refurbished in October. The work should take between three and four days to complete and service users will eat out during this time. Tiles in the kitchen above the cooker must be replaced as part of the refurbishment programme and a new fridge freezer purchased. The inspector discussed with the registered manager the need to reduce the number of plugs in the adaptor behind the television in the lounge. The garden is to be maintained; lawns are to be cut, weeds eradicated and a more appealing landscape developed. Flashings have become detached from the front of the property and must be repaired, replaced and the broken ones removed from the rear garden. Please see requirements section of this report.
High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 14 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): 33 Staffing within the home must be reviewed and sufficient staff must be on duty in addition to the registered manager to meet the needs of service users. EVIDENCE: During the inspection the registered manager was the only member of staff on duty. The inspection was shortened because the service user was due to go out at lunch-time and the registered manager was to escort him to his appointment. The registered manager informed the inspector that staff have been working at the home for some time and were progressing well with their training. Please see requirements section of this report. High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 15 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): 37,41 Systems in place for the effective management of the home must be improved. The home has a clear set of policies and procedures in place. EVIDENCE: Current data in records was not easy to locate within the filing system adopted and discussion was held with the registered manager regarding the need to archive some of the information in order to make the current information more accessible. Assistance with record keeping, filing, and general administration must be provided to enable the smooth running of the service. The registered manager has completed his NVQ Registered Managers award and is awaiting certification. Please see requirements section of this report. High Street (31) DS0000013486.V255795.R01.S.doc Version 5.0 Page 16 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 3 3 X X 2 Standard No 22 23 Score X X 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 2 X X X 2 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
High Street (31) Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X X X 2 X X DS0000013486.V255795.R01.S.doc Version 5.0 Page 17 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 YA5 Regulation 5 (1) (b) (c) 16 (2)(g) 23 (2)(b) 13 (4) (c) 23 (2) (b) Requirement Service users contracts must be reviewed and updated and outline the current terms and conditions of stay. The Fridge/Freezer in the kitchen must be replaced and the kitchen refurbished as planned. The number of plugs in the adaptor behind the television in the lounge must be reduced. The garden to the rear of the property must be maintained, weeds eradicated and a more inviting environment developed. The flashing board, which has become detached from the front of the property must be replaced and removed from the rear garden. The staffing structure for the home must be improved to ensure that staff are available in addition to the registered manager. The storage of records within the office must be improved and records archived where necessary. Assistance with record keeping, filing, and general administration must be
DS0000013486.V255795.R01.S.doc Timescale for action 31/12/05 2 3 4 YA28 YA24 YA28 30/11/05 30/11/05 31/01/06 5 YA24 23 (2) (b) 31/12/05 6 YA33 18 (1) (a) 30/11/05 7 YA41YA37 17 (1)(a) 17 (3)(a) 30/11/05 High Street (31) Version 5.0 Page 18 provided to enable the smooth running of the service. 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.V255795.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
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