Inspection on 28/04/05 for Malvern

This inspection was carried out on 28th April 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 13/10/05

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 10 Ringley Gardens Horley Surrey RH6 7HA Lead Inspector Deavanand Ramdas Unannounced 28th April, 05 at 10am 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. Malvern Version 1.10 Page 3 SERVICE INFORMATION Name of service Malvern Address 10 Ringley Avenue, Horley, Surrey. 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) O1293 430686 Ashcroft Care Services Andrew Vinnicombe Care home only 6 Category(ies) of Learning disability (LD) registration, with number of places Malvern Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be: 18-65 years. Date of last inspection 19th October 2004. 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 communual lounge, a dining room, a kitchen, bathroom with a shower, laundry facillties 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 6 hours. This was a routine visit to the home as part of the Commission’s inspection programme. A tour of the premises took place, staff and service users were spoken to and records were inspected. The Manager, Acting Deputy and five staff were spoken to by the inspector as well as four service users. What the service does well: What has improved since the last inspection? What they could do better: The standard of the environment within the home could be improved by changing the carpets to three of the bedrooms, the corridor and main stairs so as to provide service users with an attractive and homely place to live in. The Commission for Social Care Inspection has made requirements for action in respect of these matters which are detailed on page 20 of this report. The care plan of one service user needs be reviewed to take account of the health and safety risk when this individual is in his bedroom. Other areas for improvement included the updating and amendment of some of the homes records and information. In addition, the arrangement for service users meals may benefit from the advice of a dietitian. Malvern Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Malvern Version 1.10 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 Malvern Version 1.10 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) 1,2. The Statement of Purpose and Service User Guide are good. However, they must be improved to ensure service users have up to date and accurate information on which to make their decisions. EVIDENCE: There was a Statement of Purpose in the home. It was clearly written and contained a lot of information to do with how the home operated and what service users could expect if they chose to live at the home. The Statement of Purpose needs to be updated to reflect the change in name of one of the partners and also the complaints section needs to be updated to reflect the change from National Care Standards Commission to the Commission for Social Care Inspection. Each service user had a service user guide. The guide was written in plain and simple language and it was also translated using symbols/pictures. The inspector found one service user did not have a contract in the service user guide and that other contracts must be updated by removing the name of a former partner. The Manager reported, that the Statement of Purpose and service user guides were available to service users. Two service users informed me they both had their service user guide in their bedroom. Malvern Version 1.10 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) 6,7,9. The home must ensure, where a service user is allowed to make independent choices that such choices are appropriately risk assessed and risk managed to ensure the safety of the service user and others. EVIDENCE: During the inspection of the premises, the bedroom of one service user was found to be in an untidy state. The Manager informed the inspector that the service user made independent choices and was assisted and prompted by staff to maintain a safe environment. However, the Manager and the inspector identified a number of health and safety risks in the bedroom for example, a computer monitor was encased in a wooden box that was placed on top of a workstation that appeared to be unsteady, a television was found to be near to a wash hand basin and also partly blocking the entrance to the bedroom. The Care Plan was checked and found to contain a pen profile, guidelines for management, medication details, tick charts, seizure charts, cooking charts, activity programmes, risk assessments, a record of finances. In addition there was a room clean schedule and an electricity safety chart. All of the Care Plans were reviewed on the 5.4.05. However, the records show that the key worker did not sign the risk assessments and that the last entry in the room clean schedule chart was Nov 04. The electricity safety chart was also found to be Malvern Version 1.10 Page 10 incomplete. The Manager and Acting Deputy both agreed this area of care needed to be risk assessed again to minimise any health and safety risk to the service user. Malvern Version 1.10 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) 17 The dietary needs of service users are adequately catered for at present. The menu plan needs to be reviewed to ensure that it continues to meet service users tastes and choices. EVIDENCE: During the inspection, the inspector observed one service user being supported by a staff to bake a cake. He also made his own lunch of egg on toast. The inspector had a meeting with staff during which, they said, they would like to see the menu reflecting more variety. They informed the inspector, they had Jamaican food one evening and that the service users enjoyed it. In addition, they informed the inspector, that the menu could be improved by having more freshly cooked food. When asked by the inspector, the staff reported that the menu plan did not have input from a dietitian or a nutritionist. This area was discussed with the Manager and he said he would look at the menu again to see whether more fresh food could be provided. He also said that there are cost considerations that he had to take into account due to his weekly budget. The inspector spoke to two service users who said they were happy with the meals provided at the home. Malvern Version 1.10 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 standard(s) 18 and 19 The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: A key worker system was in place at the home. The inspector spoke to two service users, they both stated, they were happy with their key workers. One service user said he had been on a sponsored walk with a member of to raise money for a trip to Scotland. A member of staff informed me that service users were independent and able to exercise their own choice about a lot of things including dress, activities and holidays. The Acting Deputy stated that a holiday was being planned to Devon. The service users spoken to by the inspector were excited about the holiday. During the inspection, one service user was taken to see his local GP and also taken to the chiropodist. At handover, the Acting Deputy reported that the service user was pleased with his appointment and everything went well. Malvern Version 1.10 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 standard(s) 22,23 The staff team had a good knowledge and understanding of Adult Protection issues to protect service users from abuse. EVIDENCE: The home had a Complaints Policy that was kept in the Policies and Procedures File. There was also an information leaflet about how to make a complaint on the wall by the front porch and on the notice board. There was written evidence that staff had read and signed the complaints policy. They were able to find the complaints policy and were able to describe the contents when asked by the inspector. During the inspection, the inspector witnessed a service user who went to the office to see the Manager to raise concerns about why he could not go out for his lunch at McDonald’s that day. The Manager explained to him that he had a Drama class and that his lunch out would be later that day. The service user was happy with the explanation he was given. There was an Abuse Guidance Policy in the Polices and Procedure File. There was evidence that staff had read and signed this policy as well. One staff reported, service users are well looked after and there is enough staff to do the job. The Acting Deputy stated there were no accidents or incidents, complaints made, nor any physical restraint used since the last inspection. Malvern Version 1.10 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 standard(s) 24,25,26,27,28,29,30 The overall state of the environment is good but investment is needed to replace some of the carpets in the bedrooms, corridors and stairs to create a more pleasing and pleasant environment to live in. EVIDENCE: On the day of the inspection, the inspector found the lounge, dining room, kitchen, bathroom and toilets to be clean. The décor of the home was generally of a good standard. There was adequate heating, lighting and ventilation. The inspector found four of the bedrooms to be personalised and pleasantly decorated. Bedrooms had televisions, radios, posters, educational certificates and family photographs. One service user had achieved an NVQ Level 2 in Horticulture. The service user stated, he was proud of his achievement. Another service user informed the inspector, he liked living at the home. The fifth bedroom was found by the inspector to be untidy and in need of cleaning. The inspector pointed this out to the Manager during the inspection. The carpet in three of the service users bedroom was found to be old, worn and threadbare. The carpet in the corridor and stairs was also in need of replacement. The gardens to the front of the building and to the rear were well maintained. One service user said he liked sitting in the garden when the sun was out. Malvern Version 1.10 Page 15 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) 34 The home has good recruitment procedures that ensured staff employed did not pose a risk to the service users. The home must ensure that CRB documentation is up to date and available for inspection at the home. EVIDENCE: The inspector sampled the Manager’s personnel file and it contained all of the relevant documents relating to recruitment. The home had a policy on the recruitment and selection of staff and the manager was able to identify all of the recruitment documents needed for new employees. The home does not have any volunteers. The home had a record of staff that had a CRB check that was found to be out of date. The Manager contacted the Head Office and the relevant information was given to the inspector on the day. The home also has a policy on equal opportunities. One service user said, he was happy with the staff and they all treated him well. Malvern Version 1.10 Page 16 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. The staff team is motivated and enthusiastic and worked positively with service users to improve the quality of their lives. EVIDENCE: The home was observed to be well run. The Manager reported, he had recruited staff and there was 1 vacancy. He also said that staff from the home went on secondment to other homes to share their competency and skills. During the inspection, the inspector had a group meeting with four members of staff. They reported to the inspector that the home was well managed and that they were included in making decisions about the home. They said, communication and team working was good. The Manager was described as, a good manager with a relaxed style, approachable and easy to talk to. The Manager stated that he would like the Acting Deputy to be involved in the inspection as part of her development. The Manager made arrangements for the Acting Deputy to work with the inspector during the afternoon period of the inspection. One service user said to the inspector, he quite liked it here (Malvern). He said, he liked all the staff and clients and wanted blue carpets for his bedroom. Malvern Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 3 3 3 3 3 Standard No Malvern Version 1.10 Score Page 18 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score x x x x x x 3 31 32 33 34 35 36 x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x Malvern Version 1.10 Page 19 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 24 Regulation 23(2)(b) (d) Requirement The carpets in the corridors and stair carpeting must be replaced. This requirement was in the previous inspection report of the 19th October 2004 and has not been met. The carpets in three service users bedrooms must be replaced. This requirement was in the previous inspection report of the 19th october 2004 and has not been met.. The registered person must undertake a risk assessment of one service users bedroom in order to assess and manage the risks associated with health and safety. The registered person must ensure that a contract for the provision of services for one service user is contained in the service users guide and that all other contracts are updated. The registered person must ensure that the Statement of Purpose is updated to reflect the change in name of one of the partners and once updated that a copy be sent to the Commission. Version 1.10 Timescale for action 01.08.05 2. YA 24 16(2)(c) 01.08.05 3. YA 9 13(4)(a) (c) 01.07.05 4. YA 5 5(1)(b) (c) 01.07.05 5. YA 1 4 (1)(c) 01.07.05 Malvern Page 20 6. YA 9 17(3)(a) 7. YA 34 19(5)(d) (i) The registered person must ensure where risk assessments are undertaken they are signed by the key worker. The registered person must ensure where CRB disclosures are obtained that such information is up to date and available in the home. 01.06.05 01.06.05 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. Refer to Standard YA 17 Good Practice Recommendations The registered manager should consider having the menu plans reviewed by the community dietitian. Malvern Version 1.10 Page 21 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 Malvern Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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