Inspection on 13/10/05 for Malvern

This inspection was carried out on 13th October 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

Malvern 28/06/07

Malvern 28/04/05

Malvern 19/10/04

Malvern 20/05/04

Similar services:

Southfields

Thorndene

Insight - Eastchurch

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 Malvern Malvern 10 Ringley Avenue Horley Surrey RH6 7HA Lead Inspector Peter Benthom Announced Inspection 13th October 2005 10:00 Malvern DS0000013710.V258348.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 Malvern DS0000013710.V258348.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. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Malvern Address Malvern 10 Ringley Avenue Horley Surrey RH6 7HA 01293 430686 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) Ashcroft Care Services Ltd Mr Andrew Vinnicombe Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 65 YEARS 28th April 2005 Date of last inspection Brief Description of the Service: Malvern is a six bedded home for service users with a learning disability. It caters for both male and female service users and is located in Horley, within walking distance to the town centre. The home is a large detached house. On the ground floor is an office, a communal lounge, a dining room, a kitchen and bathroom with a shower, laundry facilities and two service user bedrooms. On the first floor there are four-service users bedroom, a sleeping in room for staff and a bathroom with a shower. All service users have their own bedrooms. The home has a front and rear garden, which is well maintained, and private parking is available. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second of the year 2005/6 and was conducted by an inspector from CSCI. The manager has been in post since 2000 and was present for the inspection. The acting deputy manager was also present for the inspection. Three members of staff were on duty. One Service User has 1 to 1 support. Three of the Service Users were spoken with during the course of the inspection. A tour of the premises took place and care, training and Health and Safety records were inspected. The home provided a high level of support to service users. What the service does well: What has improved since the last inspection? Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. Each service user has a clearly set out care plan and all the service users are registered with a GP. There were satisfactory facilities and procedures available for the safe reception, storage, disposal, administration and recording of medication. Arrangements are in place to meet service users care needs in a respectful way that affords both privacy and dignity. Staff are committed to encouraging service users to take part in activities offered in the home. Full support is provided to enable individual choice in daily living activities. Care plans have been drawn up, with the help of the service users’ families/representatives and other professional outside agencies who are familiar with the service users. The individual care plans were well documented and covered areas of care needs for each service user. A range of activities is in place for the service users to participate in. Service users are encouraged to visit their families and staff will offer support. Some good relationships between staff and service users’ families were evidenced. Service users have regular outings and they go on excursions and holidays. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 6 The home has a key worker system in place and each individual service user had a key worker. The key worker with support from the management team was responsible for developing and reviewing the service users’ care plan. Staff ensured that specialist support was provided were necessary. 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. Malvern DS0000013710.V258348.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 Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The management team were able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The statement of purpose was professionally produced and was considered comprehensive and contained all the relevant information required by schedule 1 of the Care Homes Regulations 2001. The manager is competent to carry out full assessments on service users prior to admission. Relatives and/or representatives are involved in this process when service users have problems expressing themselves. Observation and discussion with staff members and an inspection of records indicated that the home had the capacity to meet the service users’ assessed needs. The registered manager stated that unplanned admission to the home is avoided and emergency placement would not be considered. Malvern DS0000013710.V258348.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, 7, 8, 9 and 10 The systems for Service User consultation are good with a variety of evidence that indicates Service Users views are both sought and acted upon. EVIDENCE: Each service user has a care plan in place, which is thorough and covers the assessed needs of the service user. Care plans reflect involvement from other agencies such as the local GP and primary health care teams. It was evident that the needs of individual Service Users were identified and an action plan put in place to meet their needs. There was evidence of reviews being carried out by the key workers and of the action taken as a result of the review. It is general practice at Malvern to involve Service Users in a number of daily activities within the home. There are regular Service Users meetings held and they are given the opportunity to express their views. There was evidence that risk assessments were usually carried out on each of the service users on a regular basis. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 10 Staff are aware of the need for confidentiality and are aware that information about service users is confidential. They are aware of the home’s policy, which is clear and to the point. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 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, 12, 13, 14, 15, 16 and 17 Activity programmes are varied and on the whole are designed to meet individual need. Links with the families, friends and the local community are good. EVIDENCE: All Service Users have full and varied activity programmes. Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. Service users attend various day centre and adult education activities. A different variety of community-based activities are available. The activities programme was individualised in accordance with service users wishes and made appropriate use of college courses, community amenities and facilities. Service users had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Staff attempt to maintain links with Service Users’ families. Any visitors could be entertained either in the service user’s own room or in the garden. Friends are invited to visit. The home has Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 12 maintained some good family links. There are no restrictions in terms of visiting times. There was evidence in the care plans that service users are supported to be as independent as possible, and are free to make decisions where possible. The service users were free to move around the home consistent with individual risk assessments in place. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 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): 18, 19 and 20 The healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: The home had adopted a key worker system and each individual service user had a key worker who knew them and their family well. The key worker with support from the management team was responsible for developing and reviewing the service users’ care plan. Staff ensured that specialist support was provided where necessary. All service users are registered with the local GP. A local surgery provides health care to the service users, which includes health checks, continent assessment and some staff training. The arrangements for all aspects of administration of medication appeared to be satisfactory. Medicines for each service user were recorded and stored accordingly in line with the RPS (Royal Pharmaceutical Society) guidelines. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 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 and 23 The home has a satisfactory complaints system that is made available to all Service Users and staff. EVIDENCE: The complaint procedure was compliant with statutory requirements and is provided in pictorial form for Service Users. Complaint forms were available for recording complaints. Records demonstrated there had been no formal complaint received by the home or the regulator within the last twelve months. The organisation had its own adult protection policy formulated in 2002 and a copy of Surrey’s multi-agency vulnerable adult abuse procedure was available in the home. The subject of abuse was addressed within the staff induction programme. Up to date training in the Protection of Vulnerable Adults will be talking place on an ongoing basis. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 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): 24, 25, 26, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. However some replacement and completion of outstanding building work is urgently required. EVIDENCE: The position of the home is suitable for its purpose; it is easy to get to, safe and well maintained, meeting service users’ individual and shared needs in a comfortable and informal way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The premises were bright, homely and comfortable. The lighting and heating appeared sufficient as to meet the needs of the service users. Service users bedrooms contain furniture and fittings that were homely and non-institutional and these were provided with full discussion with service users. There are two bathrooms and toilets available for service users, although one is not in use at present owing to the uncompleted building work. The shared and private areas in this home are of a very good standard. The premises were clean and tidy and odour free. Infection control systems are Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 16 in place. There were appropriate arrangements in place for hand washing and for the washing of personal clothing. The upstairs shower has been out of action for the last eight weeks and as such there is insufficient facilities for service users. The central heating boiler in the kitchen is old unsightly and noisy and requires replacement. Please see requirements on Page 20 Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33, 34, 35 and 36 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. At the day of the inspection personnel files were seen and considered to be accurate. All documents required by Schedule 2 of the Care Homes Regulations 2001 were available in individual files. Staff meetings are in place and are organised monthly. Staff meeting-minutes were seen as part of the inspection process. The manager gave evidence of a professional and comprehensive induction period for new members of staff. Staff confirmed that they receive training on a regular basis. All members of staff receive supervision on a regular basis. The deputy manager of the home carries some supervision responsibilities and the manager provides supervision to the deputy manager. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 18 50 of staff have completed or are undertaking NVQ training. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 19 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, 38, 39, 40, 41, 42 and 43 The manager has a clear development plan and vision for the home, which she has effectively communicated to the Service Users, staff and relatives. EVIDENCE: There is good leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. The manager is fully aware of the needs of the Service Users in the home and as such is able to communicate this to staff through regular staff meetings and individual supervision sessions. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 20 The manager has been in post since 2000 and illustrates a full commitment to the home and its Service Users. The frequency of staff meetings and informal supervision was indicative of an open and supportive atmosphere. Regulation 26 (Monthly visits by the proprietor) are undertaken and evidence was seen of their occurrence. Relevant policies and procedures were in place. Systems existed to demonstrate these had been communicated to staff. Also those of relevance to service users had been shared with them. Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. They were seen to be in good order. There were policies and procedures in place for the health, safety and welfare of service users and staff. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Malvern Score 3 3 3 N/A Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000013710.V258348.R01.S.doc Version 5.0 Page 22 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 Regulation 23 (2) (j) Requirement The upstairs shower is currently out of use and has been for approximately eight weeks. This must be attended to with immediate effect in order for service users to use all facilities in the home The home’s boiler is old, unsightly and inefficient and requires replacement. Staff meeting minutes must be typed in the future in order to ensure that they may be examined at the next inspection. Timescale for action 30/11/05 2 23 (2)(c) 30/12/05 3 17 (1)(a) 31/10/05 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 Malvern Refer to Standard YA41 Good Practice Recommendations It is recommended that all out of date information DS0000013710.V258348.R01.S.doc Version 5.0 Page 23 contained in files is archived Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 24 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 Malvern DS0000013710.V258348.R01.S.doc Version 5.0 Page 25 - 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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