Inspection on 05/01/06 for Inglewood House

This inspection was carried out on 5th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Inglewood House 08/08/07

Inglewood House 09/05/06

Inglewood House 21/09/05

Inglewood House 18/05/04

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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 Inglewood House Inglewood House 56 Middle Gordon Road Camberley Surrey GU15 2HT Lead Inspector Denise Debieux Unannounced Inspection 5th January 2006 09:30 Inglewood House DS0000013686.V258349.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 Inglewood House DS0000013686.V258349.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. Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Inglewood House Address Inglewood House 56 Middle Gordon Road Camberley Surrey GU15 2HT 01276 64776 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) The Regard Partnership Limited Mrs Elizabeth Gail Hayes Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home may accommodate up to 1 (one) named resident with both LD & MD, Learning Disability/Mental Disorder within the total number of residents. The age/age range of the persons to be accommodated will be 24 - 65 years. The home may accommodate one service user with a mental disorder (Category MD) In the case of one named service user the age category will be reduced from 24 to 20 years of age. The home may accommodate up to 1 (one) resident with both LD & PD, Learning Disability/Mental Disorder within the total number of residents accommodated 22nd September 2005 Date of last inspection Brief Description of the Service: Inglewood House is a semi detached house situated in a residential area of Camberley, and is within a few minutes walking distance from the town centre. The home is registered to provide care for up to 12 service users in the category of younger adults. The accommodation is provided over two floors, with communal areas on the ground floor, and bedrooms on the ground and first floor. All bedrooms are single, with a wash hand basin. There is a pleasant rear garden which is accessible to service users. Parking is mainly on-street parking. Inglewood House DS0000013686.V258349.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 4.5 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs Elizabeth Hayes (Manager) was present as the representative for the establishment. A tour of the building took place with seven of the twelve service users and four on-duty staff being spoken with during the tour. The care plans, staff recruitment information, activity schedules and policies and procedures were all sampled. The inspector would like to thank the service users, manager and staff 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: Requirements have been made regarding staff recruitment which need to be addressed to protect the safety and well being of the service users. Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 6 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. Inglewood House DS0000013686.V258349.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 Inglewood House DS0000013686.V258349.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): NONE EVIDENCE: Standard 2 was fully assessed and met at the last inspection and was not covered on this occasion. Inglewood House DS0000013686.V258349.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 and 7 The service users’ individual plans are clear and comprehensive and include details of needs and goals. Service users are encouraged and assisted to make decisions about their lives with any restrictions being based on risk assessments and clearly documented in their care plans. EVIDENCE: Service users spoken with were complimentary regarding the care they receive at the home. Care plans inspected were comprehensive and set out actions which need to be taken by care staff to ensure that all aspects of the health and personal care needs of the service users are met. These care plans were seen to be based on individual assessments and were built around the services user’s individual preferences and choices. From observations made at this inspection it was clear that the staff respect the service users’ rights to make decisions. Inglewood House DS0000013686.V258349.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): NONE EVIDENCE: These standards were fully assessed and met at the last inspection and were not covered on this occasion. Inglewood House DS0000013686.V258349.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): 20 Sound policies and practices are in place for the administration and management of medications. EVIDENCE: Records were seen which showed that medication was given as prescribed and recorded appropriately. The recommendation made at the previous inspection, that any ‘as required’ drug is signed if refused, has been met. Inglewood House DS0000013686.V258349.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): 22 All required policies and procedures are in place to ensure that service users feel their views will be listened to. EVIDENCE: There have been no complaints since the previous inspection. The complaints procedure was inspected and now includes the contact details for the local CSCI office. The complaints procedure is now also available to service users in picture format. Inglewood House DS0000013686.V258349.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 The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well-maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: The home was toured and found to be in a good state of repair. Furniture and furnishings were seen to be of good quality and well maintained. All bedrooms were well decorated, furnished and highly personalised to each service user’s choice. This inspection took place shortly after the Christmas holiday and the home was bright and cheery with festive decorations. The service users spoken with all said they enjoyed their Christmas and spent time showing the inspector the presents they had received. At the time of inspection the home was warm and bright with a homely atmosphere with the service users showing a clear sense of ownership over their home. Inglewood House DS0000013686.V258349.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): 32 and 34 The home has a staff training programme which is designed to ensure that service users are supported by competent and qualified staff. Arrangements for staff recruitment are not satisfactory and are placing service users at possible risk of harm or abuse. EVIDENCE: The manager expressed a strong commitment to training for the staff. The home have been working towards having 50 of their care workers qualified to NVQ level 2 in care or higher by 31st December 2005. At present four of the nineteen care workers have already achieved NVQ level 2 qualifications and seven are currently undergoing the training. During the inspection two staff files were sampled. On their application forms there were unexplained gaps in employment and the members of staff had not given a full employment history, one did not have a current photograph and there were inconsistencies in the date of birth. Both files had proof of identity and in both cases the home had obtained Criminal Records Bureau certificates. Requirements have been made regarding staff recruitment. All interactions observed between staff and service users were seen to be respectful and caring and the service users were relaxed and comfortable in the company of the staff they were with. Inglewood House DS0000013686.V258349.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 and 39 Service users benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. EVIDENCE: Mrs Hayes has been the manager of Inglewood House for the past four years and holds the Registered Manager’s Award. The company’s quality assurance department has carried out a survey with service users and relatives. The manager stated that she is waiting for the results of the surveys to be sent to the home. Once received an action plan will be drawn up to address any issues raised, a copy will be given and explained to all service users and a copy placed in the service users’ guide. The requirement made at the previous inspection has been partly met. A recommendation has been made that the home includes GPs, Care Managers and other health and social care professionals in their quality assurance surveys. Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 16 All interactions observed between the manager, staff and service users at this inspection evidenced an open, positive and inclusive atmosphere. Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Inglewood House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000013686.V258349.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 YA34 Regulation 19(1)(b) Requirement The registered person must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). The registered person must ensure that staff files for all persons employed since 26th July 2004 contain all information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) and be satisfied as to the appropriateness of the references obtained. Timescale for action 05/01/06 2 YA34 19(1)(b) 05/03/06 Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 19 3 YA39 24(2) The registered person must ensure that the results of service user surveys are published and made available for service users and their representatives. A copy to be sent to the CSCI, Eashing office. 05/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA39.7 Good Practice Recommendations It is recommended that the home includes GPs, Care Managers and other health and social care professionals in their quality assurance surveys. Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 20 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 Inglewood House DS0000013686.V258349.R01.S.doc Version 5.0 Page 21 - 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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