Inspection on 21/07/05 for Hillcrest Avenue (40)

This inspection was carried out on 21st July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hillcrest Avenue (40) 01/02/07

Hillcrest Avenue (40) 12/01/06

Hillcrest Avenue (40) 28/09/04

Hillcrest Avenue (40) 06/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Hillcrest Avenue (40) 40 Hillcrest Avenue Chertsey Surrey KT16 9RE Lead Inspector Sandra Holland Unannounced 21 July 2005 12:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 40 Hillcrest Avenue Address 40 Hillcrest Avenue Chertsey Surrey KT16 9RE 01932 571978 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Welmede Housing Association Ltd Byfleet House, 2 Guildford Road, Chertsey, Surrey, KT16 9BJ Mr Mark Packer Care Home (CRH) 5 Category(ies) of Learning disability (LD), 3 registration, with number Learning disability over 65 years of age (LD(E)), of places 2 Physical disability (PD), 3 Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home may accommodate 3 residents with both LD (Learning Disabilities) and PD (Physical Disabilities) within the total persons accommodated 2 The age/age range of the persons to be accommodated will be: OVER 50 YEARS Date of last inspection 28 September 2004 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) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The inspection was carried out over four and a half hours, by Mrs. Sandra Holland, Lead Inspector for the service. Mrs. Thelma Miskelly, Registered Manager was initially present representing the service. A tour of the premises was undertaken and a number of documents and records, including staff files, care plans and medication administration records were examined. All four of the service users, the deputy manager and two members of staff were spoken with. The inspector thanks the service users and staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The admission policy is now followed more closely in relation to prospective service users. A risk assessment regarding a service user’s bathing arrangements has been carried out. Service user’s choice of weekend activity or relaxation is noted on the activity programme. The supper meal is now included on the menu. Appointments for service users to see their General practitioner (G.P.) are made promptly when required. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 6 Medication that has passed its expiry date is returned to the pharmacy. The manager will ensure that all references are clearly written, signed and dated. Staff supervision meetings with the manager are now occurring at the required frequency. The gas supply and boiler has been serviced. 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) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4. Prospective service users are fully assessed and have the opportunity to visit the home. EVIDENCE: The manager stated that a full assessment of service user’s needs and aspirations is undertaken to ensure that the home can meet the individual’s needs. The assessment is carried out by a care manager, but the home manager advised that she also assesses prospective service users, either in their own home or when they come to view the home. A copy of the care management assessment was seen to be included in the individual’s plan. Prospective service users are welcomed to visit the home following the initial assessment. This enables them to decide if the home is suitable and if they are compatible with other service users. It was clear from the individual plan, that trial visits to the home had taken place. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 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 standard(s) 6 and 9. Service users know that their needs and goals are reflected in their individual plans. EVIDENCE: A comprehensive, individual plan is drawn up from the assessment of the service user’s needs, the deputy manager advised. This details all aspects of the support required by the service user and their goals towards independence. Guidelines for the management of various behaviours and the involvement of specialists are also recorded in the plans. The deputy manager stated that the individual plan is amended if necessary, once the staff at the home have come to know the service user’s needs. The deputy manager advised that risks to the health and welfare of service users, such as handling their own money or moving and handling, are identified and recorded. Service users are supported to be independent within the level of risk assessed. One individual plan stated that a service user needed the assistance of two staff to walk outside the home, but this was not stated in the associated risk assessment. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 10 The individual plans are regularly reviewed within the home but service users are not able to sign to show their involvement, the manager advised. It was stated that any changes to individual plans are discussed with service users. In these circumstances, it is good practice to ask service user’s representatives to sign the plan on the service user’s behalf. Care management reviews have been arranged for some, but not all service users. Two requirements have been made – please see page 24. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 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 standard(s) and 16. 12, 13, 14, 15 Staff provide support to service users to develop their skills and to lead active lives. EVIDENCE: Staff advised that although service users are not able to undertake employment, they do enjoy a number of fulfilling activities. Service users attend a variety of adult education classes, including pottery, woodwork, cookery and gardening. The deputy manager stated that service users are involved in local community activities, which include leisure clubs, bingo sessions, visits to the theatre, markets and restaurants. She also advised that two service users had recently returned from a holiday on the south coast. All service users at the home are involved with their families, who are welcomed to visit the home. Some service users go out for visits with their Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 12 families. Additional support is available to service users if required, as contact details of a local advocacy service were seen to be noted in the individual plans. It was clear from observing staff and service users that support is provided to promote independence and choice. Staff were seen to involve service users in household activities and conversations. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20. Service users receive support in the way they prefer and their healthcare needs are well met. EVIDENCE: It was clear from observing service users and staff together, that personal support is provided according to the needs of the individual and in the way that the service users prefer. Personal support was given sensitively and discreetly and service users were spoken to in a respectful manner, using their preferred name. From the individual plans and speaking to staff, it was evident that a number of healthcare professionals are involved in the support of the service users. These include general practitioner (G.P.), chiropodist, diabetes nurse specialist, dentist and hospital specialists. The deputy manager advised that if new healthcare needs are identified, these are referred to the appropriate professional, usually by the G.P. The deputy manager stated that medication is supplied to the home by a local pharmacy, which has also provided training in medication administration to staff in the past. The administration of medication is recorded on charts that are specific to the Welmede organisation. These charts provide space for the recording of medication received into the home or returned to the pharmacist Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 14 for disposal. The records on the charts were compared with the stock of medication held in the home, but as it is not made clear when individual packs of medication supplies are started, it was impossible to calculate what the accurate stock level should be. This is not acceptable and arrangements must be made to ensure that the stock of medication and the record can be clearly checked. A requirement has been made – please see page 24. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. A complaints procedure is in place, but is not available to all. Staff are aware of their responsibilities in the protection of service users. EVIDENCE: The complaints policy and procedure were seen to be available in written and pictorial forms and to date from 2002. The deputy manager stated that due to their educational needs, the current service users are not able to understand the policy in either of these forms. The deputy manager advised that service users usually bring any dissatisfaction to the attention of staff if and when it occurs and it would be dealt with directly. As it is required that the complaints procedure is made available to service users in a way that is appropriate to their needs, it is recommended that staff explain the procedure to service users and record the explanation in each person’s individual plan. The complaints policy, procedure and the complaints record are stored in the office. Although no complaints had been recorded, it is required that the complaints procedure and record book/log are made available in a communal area, for anyone to use. The procedure also needs to be updated and to refer to the Commission for Social Care Inspection. The manager stated that staff undertake training in the Protection Of Vulnerable Adults (POVA) through the Surrey Multi-Agency service and attend refresher courses through the NSPCT. Certificates of attendance and individual staff training records were seen. Members of staff spoken to confirmed that they felt able to raise any concerns they had. A requirement and a recommendation have been made – please see page 24. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30. The overall décor and furnishings in this home provide a well-cared for and homely environment for residents. EVIDENCE: The home is a bungalow, which has been adapted to suit the needs of those living there. It is well maintained with colourful decoration and all areas are easily accessible. It is appropriately furnished and equipped to meet the needs of residents. Resident’s bedrooms are for single occupancy and are fitted with wash hand basins. Staff advised that residents are encouraged to bring items of furniture and other belongings into the home to make their bedroom more individual. Resident bedrooms seen, had been personalised with photographs, ornaments, plants and pictures. Toilets and bathrooms are situated nearby and were seen to be hygienic. The home was clean, tidy and freshly aired throughout. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 17 Large patio doors lead onto the garden and spacious patio area. The garden was planted with pots of seasonal flowers and tables and chairs were arranged on the patio. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35 and 36. Service users are supported by a stable and effective staff team, under the leadership of the manager. EVIDENCE: The manager advised that a number of staff have been employed at the home for many years. It was clear from speaking to staff that they have developed a good understanding of each service user’s needs. Staff advised that they are committed to the development of each service user, to enable them to be as independent as possible. The staff training record file was seen and from this it was clear that staff undertake regular and appropriate training, including medication administration, minimal handling, Control Of Substances Hazardous to Health (COSHH)and POVA. A number of staff have taken, or are undertaking National Vocational Qualification (NVQ) training courses and the home is on target to meet the required ratio of 50 of trained care staff. The manager stated that supervision of individual members of staff is now being carried out regularly and records confirming this were seen. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 19 Staff recruitment records were seen to contain most but not all of the required records or documentation. A full and complete employment history must be provided, by all those applying for employment in the home. Two forms of confirmation of identity must be obtained for those applicants selected for employment and both of these must be valid. Out of date documents, such as expired passports must not be accepted. A requirement has been made – please see page 24. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, and (42 partially). Service users benefit from an open and inclusive ethos and effective management of the home. EVIDENCE: The manager was present at the start of the inspection but then had to leave to attend a prior appointment. It was evident however, from the standard of record keeping and the approach of other staff, that the home is effectively managed. It was also clear that the manager has developed the staff team to manage the home in her absence. The deputy manager and staff were able to assist the inspector and provide much of the information required. A number of records in relation to health and safety were seen (but not all), and these were found to be satisfactory. The records relating to fire safety were seen and found to be up to date, with appropriate equipment in place which is regularly tested and serviced. The records of the temperature of the hot water supply were also seen. These recorded that this was within a safe range. A sample of the water supply had been sent for testing for Legionella Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 21 bacteria and the record stated that the results would follow, but no results have been received. It is advised that this is obtained, to ensure that the water supply does not pose a risk to the health and safety of service users or staff. The deputy manager advised that a comprehensive check of health and safety risks within the home is carried out each month and records of this were seen. The service was inspected by an Environmental Health Officer (EHO) within recent month and no requirements were made. A requirement has been made – please see page 24. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 22 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 x 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hillcrest Avenue (40) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 23 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 6 Regulation 14 (2) Requirement The registered person shall ensure that the assessment of service users needs is kept under review. Specifically, arrangements must be made for an annual review of needs, involving service users, care managers and service users representatives. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Specifically, risk assessments must accurately reflect service users needs. The results of the water sample sent for testing for Legionella bacteria must be obtained. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Specifically, accurate records must be maintained of the quantity of medication received and held in the home to enable an audit trail to be followed. Timescale for action 21st October 2005 2. 9 and 42 13 (4) 26th August 2005 3. 20 13 (2) To commence from 21st July 2005 Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 24 4. 22 22 5. 34 19 (1)(b) The registered person shall 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. The registered person shall not employ a person to work at the care home unless all the information and documents specified in Schedule 2 of The Care Homes Regultions 2001 (As Amended) have been obtained. Specifically, a full and complete employment history must be obtained from all applicants. Confirmation of identity must be obtained from two documents, both of which must be valid and up to date. 21st October 2005 26th August 2005 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 22 Good Practice Recommendations It is recommended that the complaints procedure is explained to any service users who are not able to read the procedure, and the explanation is recorded in the service users individual plan. Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillcrest Avenue (40) H09 H58 S13495 40 Hillcrest Avenue V237612 210705 Stage 4.doc Version 1.40 Page 26 - 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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