Inspection on 12/01/06 for Hillcrest Avenue (40)

This inspection was carried out on 12th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillcrest Avenue (40) 01/02/07

Hillcrest Avenue (40) 21/07/05

Hillcrest Avenue (40) 28/09/04

Hillcrest Avenue (40) 06/05/04

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 Hillcrest Avenue (40) 40 Hillcrest Avenue Chertsey Surrey KT16 9RE Lead Inspector Sandra Holland Unannounced Inspection 12th January 2006 14:00 Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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 Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hillcrest Avenue (40) Address 40 Hillcrest Avenue Chertsey Surrey KT16 9RE 01932 571978 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Welmede Housing Association Ltd Mrs Thelma A Miskelly Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2), Physical disability (3) of places Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate 3 residents with both LD (Learning Disabilities) and PD (Physical Disabilities) within the total persons accommodated The age/age range of the persons to be accommodated will be: OVER 50 YEARS 21st July 2005 Date of last inspection Brief Description of the Service: Hillcrest Avenue is a small home providing accommodation and support for up to five people with learning disabilities. Up to three service users may also have physical disabilities and two service users can be over 65 years of age. The home is run by Welmede Housing Association and the staff are employed by the North Surrey Primary Care Trust (NSPCT). Welmede runs a local network of homes for people with learning disabilities. The property is a bungalow specifically adapted to the needs of service users, situated in a quiet residential avenue on the outskirts of Chertsey. Accomodation is provided in single bedrooms with spacious communal areas and an attractive garden. Car parking is available on the front drive or on the road. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. As this was an unannounced inspection, no one at the home knew it was to take place. The inspection was carried out over three and a half hours, by Mrs. Sandra Holland, Lead Inspector for the service. Ms Erica Darran, Deputy Manager was present representing the service and Mrs.Thelma Miskelly, Registered Manager arrived later. Areas of the premises were seen and a number of documents and records, including the statement of purpose, service user’s guide and care plans were examined. All five of the residents and two members of staff were spoken with. As the inspector does not share the communication methods of some of the residents, their responses have been assessed by observing their facial expressions, body language and interactions with staff. Further information was provided by members of staff. The inspector thanks the residents and staff for their time, assistance and hospitality. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. To fully assess how the home is meeting the National Minimum Standards for Care Homes for Adults, it will be necessary to read the reports of both inspections. What the service does well: The service offers a high level of person centred support to a group of residents with varying needs. Residents are encouraged to be independent in as many areas of their lives as possible and to develop and maintain their skills. The accommodation is well presented in a homely style whilst meeting the needs of residents and the home blends well into its surroundings. It is clear that staff at the home provide dedicated and committed support to the residents living there. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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 Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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 and 4. A statement of purpose and service user guide provide prospective service residents with the information they need to decide if the home will meet their needs. EVIDENCE: A statement of purpose and service user guide have been produced, are comprehensive and provide the information required. These are provided to prospective residents to assist them in deciding if the home will suit them. Prospective residents and or their representatives are also welcomed to visit the home, to help them decide on it’s suitability, the deputy manager stated. A resident had moved into the home in recent months, having visited on a number of occasions, the deputy manager advised. This enabled the prospective resident to meet other residents and staff, and enabled the staff to fully assess the resident’s needs A service user’s guide has been provided to each of the residents living at the home. It was noted that one page of the statement of purpose refers to the National Care Standards Commission and this needs to be updated to refer to CSCI. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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, 7, 8 and 9. Residents are supported to make decisions and to be involved in the daily life of the home. Assessments of known risks to residents need to be carried out. EVIDENCE: The individual plan for the most recently arrived resident was seen. The manager stated that staff in the home were in the process of drawing up a new plan, now that they had got to know the resident and her needs. Staff had been following the detailed plan drawn up at the resident’s previous home, until they had fully assessed the resident. It was clear from observing residents and staff, that residents are supported to make their own decisions and choices. Residents were offered a selection of drinks and snacks and staff advised that residents are offered a choice wherever possible, such as when getting dressed. Residents are offered alternative items of clothing that are appropriate to the time of year or weather, and residents are encouraged to choose their what they prefer. To assist with decision making for resident’s holidays, staff advised that they obtain a selection of brochures of places that provide suitable facilities, and these are offered and discussed with residents. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 10 The deputy manager stated that residents are supported to assist with household tasks that are within their physical capabilities, including collecting their laundry, stripping their beds, mopping the floor and sweeping the floor with a carpet sweeper. Those residents who were able, were seen clearing the table and putting away the table mats. The manager stated that assessments of risks to the health and welfare of residents are carried out and one was seen for the most recently arrived resident. It was noted that other risks to the resident had been identified, such as the risks of choking or when moving around, but these had not been assessed. A requirement has been made. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 11 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): 11 and 17. Residents are offered opportunities to learn new skills. Wholesome and appetising meals are provided. EVIDENCE: Staff advised that residents are offered a variety of ways to develop new skills or maintain their existing abilities. Some residents attend classes to improve their life skills, such as cookery, woodwork and gardening, whist others attend more leisure based classes, such as pottery. Residents also enjoy activities in the community, including bowling, bingo and visiting places of interest. Residents are encouraged to maintain and develop their personal care skills, being supported to carry out all the tasks that they can manage, it was reported. Staff then offer verbal prompts and assistance if required. From the menu seen, it was clear that well balanced meals are offered to residents. The meal being prepared on the day of inspection looked and smelt very appetising and matched that stated on the menu plan. The manager advised that the menu is usually planned with residents at the weekend, to Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 12 enable appropriate shopping to be bought. with household shopping, staff advised. Residents take it in turns to assist Meals are served in the spacious dining area of the lounge and the table is attractively laid. Residents and staff eat together family style, the manager stated. It was pleasing to see that residents are actively encouraged to eat and drink independently, and if required, adapted cutlery, plates or cups are obtained to enable this. A resident who was having eating difficulties, is now managing very well, having been supported by staff and stimulated by the example of the other residents. Guidelines for the support of this resident in relation to nutritional needs were seen. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 13 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): These standards were not assessed at this inspection. EVIDENCE: Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The complaints procedure was not available. EVIDENCE: A requirement was made at the inspection on 21st July 2005, that the complaints procedure must be made available to all who may wish to use it. The manager stated that this had been made available, but had been moved when decorating had taken place and has not been returned. This must be made available, as staff did not know where to find the complaints procedure on the day of inspection. A requirement has been made. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32. Residents are supported by a well motivated and committed team of staff. EVIDENCE: From observing the interaction between residents and staff, it was clear that staff are interested in the residents and enthusiastic about their roles. Staff were seen to include residents in conversations and to engage with them at all times, speaking to residents in a relaxed but appropriate manner. Residents were seen to be at ease with staff and to respond in a positive way. Staff were seen to respect resident’s private space, knocking on their bedroom or bathroom doors and waiting for a response, before entering. Support for personal care was given discreetly, encouraging independence and ensuring privacy. From speaking to staff, it was clear that they know and understand the resident’s needs and are committed to meeting these. The manager stated that a number of staff have undertaken National Vocational Qualifications (NVQ’s) in care at different levels. Three staff have achieved level 2 in care and another member of staff is currently undertaking it. The deputy manager has achieved level 3 in care, is undertaking level 3 in management and the manager has completed the NVQ Registered Managers Award. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 17 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): 39. The resident’s views on the service provided have been sought. EVIDENCE: The manager stated that resident satisfaction surveys had recently been supplied and completed. These asked residents a small number of questions, including if they liked living in the home, if they felt that staff treated them with respect and whether they were happy with the food and activities. These had been completed with each of the residents by their key workers and the responses were all positive. It is recommended that any future survey of views about the service provided, is extended to families, friends, general practitioners (GP’s) and all others involved in the support of the residents (known as external stakeholders). This will ensure that a wider selection of views are obtained as to how the home is meeting the needs and aspirations of the residents. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 18 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 3 2 x 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 3 12 x 13 x 14 x 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x 2 x x x x Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 19 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 YA6 Regulation 15 (2) (b) Requirement The registered person must prepare a written plan as to how the service user’s needs in respect of her health and welfare are to be met and must keep the service user’s plan under review. The registered person must ensure that unnecessary risk to the health or safety of service users are identified and so far as possible eliminated. The registered person must establish a procedure (the complaints procedure) for considering complaints made to the registered person by a service user or person acting on the service users behalf. Specifically, the complaints procedure must be made available to all who may wish to use it, must be updated and must display the name and address of the CSCI. UNMET FROM 21/07/05 Timescale for action 17/03/06 2 YA9 13 (4) (c) 17/02/06 3 YA22 22 17/02/06 Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 20 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 YA39 Good Practice Recommendations It is recommended that any survey of the quality of the service provided, is extended to families, friends, advocates and all others involved in the support of service users. Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 21 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 Hillcrest Avenue (40) DS0000013495.V277274.R01.S.doc Version 5.1 Page 22 - 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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