Inspection on 19/10/05 for Mallow Crescent (25-30)

This inspection was carried out on 19th October 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Mallow Crescent (25-30) 04/05/07

Mallow Crescent (25-30) 09/06/05

Mallow Crescent (25-30) 15/12/04

Mallow Crescent (25-30) 05/07/04

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Thorndene

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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 Mallow Crescent (25-30) 25-30 Mallow Crescent Guildford Surrey GU4 7BU Lead Inspector Vera Bulbeck Unannounced Inspection 19th October 2005 10:30 Mallow Crescent (25-30) DS0000034879.V254324.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 Mallow Crescent (25-30) DS0000034879.V254324.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. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mallow Crescent (25-30) Address 25-30 Mallow Crescent Guildford Surrey GU4 7BU 01483 455879 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) rosie.broomer@surreycc.gov.uk South West Surrey Adults & Community Care Services Rosemary Ellen Broomer Care Home 35 Category(ies) of Learning disability (35), Physical disability (1) registration, with number of places Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Accommodation and services may be provided to named persons aged 65 years and over with prior written agreement of the CSCI. Respite care may be provided to a maximum of 6 persons at any one time, these persons should be grouped into the same unit, House 28 To accommodate one service user with a Physical Disability. Date of last inspection 9th June 2005 Brief Description of the Service: 25-30 Mallow Crescent consists of six purpose built houses situated in Burpham. The houses are set at the end of a crescent in a quiet residential area, which is well kept. Each house has a front garden and a medium sized garden at the rear of the house. There is adequate car parking for several cars at the front or side of each house. Five of the houses are for long-term placements, with the sixth house offering respite care for five places. Each house has a large and airy lounge/dining room, appropriately furnished, with access to the rear garden. An open plan kitchen is adjacent to the dining room. All the bedrooms are single occupancy and are nicely decorated and meet the needs of the residents. The home is registered to accommodate thirty-five people with a learning disability. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to be undertaken by the Commission for Social Care Inspection year April 2005 to March 2006. Mrs Vera Bulbeck and Mrs Sandra Holland, Regulation Inspectors, carried out the inspection. Mrs Rosie Broomer the registered manager for the home was present. The inspection was undertaken over 7 hours and 15 minutes. There are currently thirty-two residents living in the six houses, and the majority have lived in the home for some considerable time. All the residents were out at day centres and work environments on the day of inspection; and the inspectors were able to speak with the residents in the evening during suppertime. A number of staff was spoken to and one commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. The inspector received a comment card from the Community Learning Disability Team, which made very positive comments. It was disappointing to note that three requirements from the previous inspection were not met. As a matter of priority the home needs to update the homes Fire Risk assessment to include all rooms and communal areas of each house, as well as introducing an emergency plan in the event of a major incident. The inspector would like to thank the manager and staff members for their time, assistance and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report What the service does well: The manager and staff team are committed to providing a safe and homely environment for residents. Resident’s are encouraged to engage in the daily running of the home and their views are continually sought to improve the service the home provides. This is maintained by the use of listening, sign and body language. The registered manager informed the inspector that questionnaires have been implemented and sent out to families and an advocate for feedback on the services provided in the home. The homes complaints procedure for residents is the best the inspectors have seen and residents use it when necessary. The complaints form is written with widget symbols and easy for residents to understand. The inspector receives Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 6 all copies of resident’s complaints. These include and identify the way in which the management of the home deal with the complaints appropriately. It was pleasing to note that residents are involved with the recruitment of staff an interview form has been developed specifically for residents in picture/symbol form and residents are able to ask questions to the applicant. 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. Mallow Crescent (25-30) DS0000034879.V254324.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 Mallow Crescent (25-30) DS0000034879.V254324.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 and 5. Statements of purpose for each house have been drawn up. Contracts between the home and residents are in place for some but are still not available for all. EVIDENCE: The manager stated that the statement of purpose, which details the service provided to residents, had been updated to reflect each of the individual six houses. These were available in each house and were on the table in the entrance hall, ensuring they were accessible to anyone. The statements of purpose were seen to contain the required information. It was noted that the house number referred to in the statement of purpose in two houses referred to a different house number, but it is likely that this is a printing error. A previous requirement that each resident is provided with a contract or statement of terms and conditions has not been fully met. Contracts were held on file for most but not all residents. Mallow Crescent (25-30) DS0000034879.V254324.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): 7. Residents are well supported to make decisions. EVIDENCE: Staff stated that residents are supported to make decisions affecting their lives in a number of ways. Each resident has an allocated lead worker, who is trained to offer one to one support and who knows the resident well and understands his or her needs. Resident meetings are held to enable residents to make decisions and choices, for holidays, menu planning and outings. For example residents spoke of attending the meetings and notes of a meeting were seen on the notice board. Resident’s individual choices of meals were recorded on the weekly menu plan. Staff advised that information is provided to residents to assist with decisionmaking and this is in a format to suit their individual needs. Information is provided in makaton, pictorial or visual formats and staff also give information verbally, as appropriate. Mallow Crescent (25-30) DS0000034879.V254324.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): 16. Resident’s rights and responsibilities are recognised. EVIDENCE: Staff stated that they actively encourage and support residents to be independent, to make their own choices and to live their lives as they wish, as far as they are able. Household routines are kept to a minimum and are only in place to enable residents to share their home’s facilities and to maintain harmony within the household. The degree to which residents are involved in the running of their home is described in the statement of purpose for each house. A pictorial rota for household tasks was displayed on the kitchen notice board in one of the houses. Staff stated and it was observed, that they knock before entering resident’s bedrooms and that personal care is offered discreetly. Residents are addressed in the way that they prefer and this is recorded in their individual plan. Residents are registered on the electoral roll, but staff advised that the majority of residents do not go to vote as their capacity to select from the candidates is limited. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 11 Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. The administration of medication is effectively carried out. EVIDENCE: The system for medication administration was seen in a number of the houses and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets were seen and no gaps in the recording were noted. Staff stated that house leaders, who report in turn to assistant team managers, monitor the MAR sheets. Any recurring gaps or errors would be referred to the supervisor of the appropriate staff member, and this would be discussed at a supervision meeting. It was pleasing to see that guidelines are in place for medication that is given “as required”. A photograph of each resident is provided with the MAR sheets to guide staff to the correct resident and a medication information sheet gives details of the medications for each resident. Staff stated that any additional entries to the MAR sheet, which have been handwritten on, are signed by the member of staff making the entry and by a second member of staff who checks that it is correct. This had been carried out. Two staff sign the MAR sheet for all medication given and for the receipt of medication into the home. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 13 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 and 23. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: There were seven recorded complaints since the previous inspection and all were from residents, there were no external complaints. Records seen indicated all had been responded to within the guidelines. The homes complaints procedure for residents is the best the inspectors have seen and residents use it when necessary. The complaints form is written with widget symbols and easy for residents to understand. The inspector receives all copies of resident’s complaints. These include and identify the way in which the management of the home deal with the complaints appropriately. The home follows the Surrey Multi Agency Procedure for the Protection of Vulnerable Adults and a copy of the updated procedure was seen in the homes. Staff spoken to, stated that they had undertaken training in the protection of vulnerable adults and would report any concerns they had to their line manager. If they had concerns about their line manager, they would be reported to the area manager. Staff said they would be willing and able to report any concerns and “would go to any level to protect residents”. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 14 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, 27 and 30. 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 residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were found to be clean and hygienic all staff to be congratulated on the cleanliness of the homes. The majority of areas have had paper towel dispensers fitted leaving bathrooms with cotton washable hand towels. The inspector would recommend that all bathrooms have paper towels to ensure the risk of cross infection is eliminated. Staff stated that each resident has their own bedroom and these had been made personal with pictures and posters, televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size and some residents had personal computers and desks fitted in their bedrooms. A number of residents showed their bedrooms, of which they were justifiably proud. It is pleasing to see that each room is individually decorated and residents are supported to choose the colour schemes to suit their preferences. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 15 One resident had recently changed rooms, to a preferred position, as a room became vacant. It had been re-decorated in her choice of colours and her lead worker spoke with the resident of going to buy new bedding, to match the room. A large lounge, which is open plan to a dining room and kitchen, forms the main communal area of the homes. These were decorated in a different colour scheme in each house and it was noticeable that although each house has a similar layout, they each have a distinctly different “personality”. The houses are furnished to a good standard to suit the needs of the residents. French doors from the lounges open onto an enclosed garden to the back of each house and some houses have a very pleasant view beyond the garden, over nearby playing fields. Garden tables, chairs and bird-tables were seen in the gardens. One house has had a new conservatory constructed, which is in use for the residents to enjoy. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 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, 34, 35 and 36. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual residents at the home. Staffing is kept under review and provided to meet the needs of the residents at all times. EVIDENCE: It was pleasing to note that residents are involved with the recruitment of staff an interview form has been developed specifically for residents to use in picture/symbol form and residents are able to ask questions to the applicant. These views are taken into consideration when appointing staff. Records were observed and found to be of a good standard some with staff support and some have been completed independently by residents. It was pleasing to note that staff have a good understanding of the residents needs, are respectful and have a good rapport with the residents. Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. The management of the home has produced a training programme, to enable management to identify when staff require up dates to Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 17 their training. A number of training courses have been undertaken and all new staff receive an induction programme, which is covered over several weeks. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 18 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, 41, 42 and 43. Resident’s benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known. EVIDENCE: The home has an effective quality audit monitoring system in place. The service manager completes a regular monthly regulation 26 notification visit and the report is well documented. The registered manager has produced with staff input a checklist for house leaders to ensure any outstanding issues relating to the houses are relayed to staff through supervision. The inspector received a comment card from the Community Learning Disability Team, and very positive comments were made relating to Mallow Crescent. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 19 The management of the home sends out yearly a questionnaire to all relatives, care managers and health professionals to complete, to provide feedback on the services offered in Mallow Crescent. The records observed on the day of inspection were found to be well documented and kept up to date. However, requirements from the previous inspection have been carried forward regarding a Fire Risk assessment to be completed on the whole premises room by room and an emergency plan to be in place. These documents must be contained in the fire record folder. The testing of the water for Legionella was still an outstanding requirement; this process must be completed as a matter of priority. The home has a business and financial plan and finances are controlled by Surrey County Council. However, the homes budget is well monitored by the bursar for the home. Records are maintained to a high level. Insurance cover for the home is in place; the insurance covers all Surrey County Council establishments and is not specific to any particular home. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 20 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 X X X 2 Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 4 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 4 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mallow Crescent (25-30) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 1 X DS0000034879.V254324.R01.S.doc Version 5.0 Page 21 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 42 Regulation 23 Requirement A fire risk assessment must to be undertaken on each house including every room and an emergency plan needs to be implemented. (Timescale of 22/07/05 not met.) The water must be tested for Legionella in all houses. (Timescale of 22/07/05 not met.) Shelving required under the stairs of houses 29 & 30 the current practice is a health and safety hazard. (Timescale of 22/07/05 not met.) Contracts must be in place for all residents. Timescale for action 01/12/05 2. 42 23 01/12/05 3. 42 13 01/12/05 4 5 17 Schedule 4. 02/01/06 Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 22 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 30 Good Practice Recommendations It is good practice and recommended by the Health & Safety Executive that paper hand towels be provided in all communal toilets and bathrooms. Mallow Crescent (25-30) DS0000034879.V254324.R01.S.doc Version 5.0 Page 23 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. 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