Inspection on 28/06/07 for Malvern

This inspection was carried out on 28th June 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Malvern 13/10/05

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 Cathy Clarke Unannounced Inspection 28th June 2007 12:30 Malvern DS0000013710.V343778.R01.S.doc Version 5.2 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.V343778.R01.S.doc Version 5.2 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.V343778.R01.S.doc Version 5.2 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.V343778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 65 YEARS 13th October 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 user bedrooms, 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 to the rear of the building. Fees for the service range from £1059.00 to £1763.00. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 4½ hours. Cathy Clarke, Regulation Inspector, carried out the inspection. The registered manager represented the establishment. A full tour of the premises took place. Discussions were held with one person who was in the home at the time of the inspection. Returned ‘comment cards’ from residents, relatives and healthcare professionals involved with the home were also used to write this report. Three resident’s care plans and a number of other documents and files, including three staff files, were examined during the day. Fees for the service range from £1059.00 to £1763.00. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? A new shower has been fitted in the upstairs bathroom and this room has been refurbished. The boiler has been replaced. Minutes of staff meetings are now recorded and available for inspection. Records have been archived and this task is ongoing. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 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.V343778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is available for prospective service users to ensure that they can make an informed choice on whether the service can meet their individual needs and aspirations. EVIDENCE: Full assessments are undertaken prior to admission. Admission procedures are individually devised to make sure that the home is right for the particular person. Admission to the home can be either a rapid event with short visits to the home or a more protracted approach depending on the needs of the person moving in. The registered manager was aware of the need to ensure that new residents were compatible with the existing people living in the home. The residents are consulted and their views listened to on any new admissions. In advance of admission a care plan is written and this is reviewed within three months, Malvern House has an additional four-week review. The plan includes risk assessments and guidelines for staff. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7, and 9 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning could be improved with a person centred approach to care provision giving the person living in the home the opportunity to be fully involved in the decisions being made about them. EVIDENCE: The care plans including risk assessments are detailed however they lack residents or their representative’s signatures, which would provide evidence of their involvement in the production and review of their care needs. The registered manager has stated that the home will be developing care plans using a person centred planning approach. Records although detailed are cumbersome and two files exist for each person living in the home. Behavioural guidelines are in place and the individual and diverse needs of people living in the home are recorded in their care plans. Care plans have been reviewed and updated. All of the people living in the home are of White British origin. The registered manager stated that a diverse group of staff are Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 10 employed and the female members of staff provide personal care for female residents. All staff communicate well with the residents and their level of English is of a good standard. Some of the staff attend college for English language lessons. According to the Annual Quality Assurance return received by CSCI the manager manages all resident’s finances. The manager takes responsibility for monitoring of bank statements for residents. Two residents have opened their own accounts with support. All residents have an individual bank account and a named purse. This is monitored centrally by Ashcroft Care Services and an annual auditor. Relatives of one of the residents has stated that the home maintains good contact with them and responds to issues when raised whilst doing this they encourage residents to a level of independence when necessary. Their family member is currently being given specific coaching and support as he moves into supportive independent living. The resident explained during the site visit that he is looking forward to the move into independent living and that he has loved living at Malvern House. Please see recommendations section of this report. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13, 15, 16 and 17 were assessed during this inspection. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. An individualised programme of activities are available to people living in the home meeting their personal preferences, aspirations and goals in life. EVIDENCE: Residents activities are planned on an individual basis, one of the people living in the home has achieved the Silver Gateway award with Mencap. This is similar in structure to the Duke of Edinburgh awards and he went up to Scotland to take part in an expedition. There are outdoor activities coordinators based at the central office. There are lots of activities available to residents including walking the two dogs that live in the home. All of the people living in the home love having the dogs and a cat in their lives. Comments received from residents living in the home include the following: • I like living at Malvern because the staff are my friends. • I’ve got a nice bedroom. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 12 • • • I go on holidays and days out. I like living with everybody here. I have loved living here since day one. Goal plans for basic and life skills are set with key workers and monitored through record keeping, these are reported in the review report. One resident spoken to stated that he has been working with staff to enable him to gain more skills before moving into a supported living environment. He has been encouraged to do his shopping, assist with household activities and was going to start cooking on the day of the inspection. Good contact is made with relatives of the people who live in the home and on the day of inspection two of the residents were on holiday with their parents. A senior care manager has stated that residents spend time each week with their family. Comments received from relatives of those people living in the home include the following: • They try to give our son as normal a life as possible, especially with activities, which he enjoys. • The home rings me regularly and keeps me informed of any medical issues. • My son has lived at Malvern house for a little over 10 years; he seems quite happy and content. There is a varied menu on offer and alternative choices are available. Residents sit down with staff to plan the menu for the week. One of the residents likes to do his personal shopping. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19, and 20 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive assistance with their healthcare needs ensuring care is provided with respect observing their privacy and dignity. EVIDENCE: Assistance with personal care is provided ensuring the independence of the resident is promoted. Personal care is provided by appropriate gender staff and privacy is always respected. Regular health checks are carried out and appointments to healthcare professionals such as dentists and GPs are individually assessed and monitored. Feedback from the GP for the home is positive and the survey received states that the home communicates clearly and works in partnership with him, there is always a senior member of staff to confer with, staff demonstrate a clear understanding of the needs of residents and that he is overall satisfied with the care provided within the home. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 14 The service has recently changed its medication guidelines and these have been signed off and approved by the Pharmacy, which is now used by the home. The medication cabinet is situated in the staff sleep in room. There are no controlled drugs. Should medicines require refrigeration they are put in a locked container and stored in the domestic fridge. None of the residents are self-medicating at the moment. Occasionally if they are short staffed the service is assisted by shift leaders from other homes owned by Ashcroft Care Services who are trained. These shift leaders know the residents and their signatures are on the identified list of people trained to administer medication in the home. The medication administration records were correctly signed and there were no gaps identified. Returns to the pharmacy are recorded on a returns form and signed and witnessed. Monitored dosage system checked as correct. Some medicines are held in their original containers. Five members of staff are trained to administer medication and one is being trained. There is a separate training programme for staff administering rectal diazepam. All of the staff in the home have undertaken this training. The manager stated that he checks all of the as required medicine procedures regularly but that there is not a formal system in place for auditing all medication practices within the home. Since this visit written information was received confirming that formal auditing systems have been introduced which includes visits by the pharmacy every six months and the company is to conduct a quality assurance audit of medication practice Please see recommendations section of this report. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s views are listened to and acted upon and the complaints and safeguarding adult’s procedures are in a format, which residents living in the home can understand. EVIDENCE: No complaints have been received by CSCI for this home. There have been no complaints or vulnerable adult investigations since the last site visit. Residents and relatives have stated that they know how to make a complaint about the service if they needed to. There is a complaints notice on the wall in the entrance to the home. The service user guide states that service users may make a complaint and it is in a pictorial format. The home has residents from three different local authorities and they hold a copy of the Surrey and Sussex Multi Agency Safeguarding Adults policies and procedures. It has been recommended that they acquire a copy of the Merton procedures and keep these in the home. Staff have received in-house protection of vulnerable adults training and the Surrey half-day awareness course. Managers have attended a session with the Surrey Safeguarding Adults team. The protection of vulnerable adults, whistle blowing and referral to PoVA procedures have been updated. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home creates a homely atmosphere and safe environment in which to live. There are some maintenance issues which when completed will improve the overall appearance of the home for people who live there. EVIDENCE: The home is situated in a quiet neighbourhood and the gardens have recently been maintained with colourful flowers and pots. The rear garden has new furniture for residents to sit on and the registered manager has stated that the service is to create a run for the dogs. The environment of the home overall is of a good standard and creates a homely atmosphere in which to live. There are maintenance issues, which have been recommended and in particular these apply to the decoration of the lounge, dining room and kitchen. The ceiling in the kitchen has been damaged following a flood in the upstairs bathroom. The extractor fan above the cooker was in need of cleaning. Since this visit the the manager has provided written Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 17 confirmation to state theat the cooker has now been replaced and will be included on the regular night duty cleaning plan. Three of the bedrooms have been redecorated and new furniture provided and these are much improved. A new shower has been fitted in the upstairs bathroom. A new boiler was purchased last year. Some of the windows in the home are without restrictors and the registered manager has stated that risk assessments are not as yet in place. The manager has stated that the three windows to the rear of the property downstairs are to be replaced to match the other windows in the house, which will improve the overall look and ongoing maintenance. The home is clean and there were no mal odorous smells. COSHH materials are kept in a locked cupboard in the kitchen. Please see requirements and recommendations section of this report. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34,35 and 36 were assessed during this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A knowledgeable and competent team of staff meets resident’s individual and joint needs. Improvements to the frequency of staff supervision sessions would ensure that people living in the home would benefit from a more informed staff group. EVIDENCE: Each member of staff is issued with a job description outlining their roles and responsibilities. Staff seen during the inspection site visit were able to work competently with residents in their care. Staff are issued with a code of conduct and the General Social Care Council code of practice. Recruitment of staff is undertaken by Ashcroft Care central office. Malvern House is an equal opportunities employer, the Ashcroft Care Services application form reflects this, there is an equal opportunities policy and this is included as part of induction. One of the records sampled did not include the months of previous employment but this was for a member of staff who has been with the Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 19 organisation for eight years. Another record is awaiting a second reference and this has been requested. A training plan is in place and the organisation employs a training manager. An induction programme is undertaken by staff and a core mandatory training programme. Three of the staff files sampled did not contain evidence of infection control training. Equality and diversity training is provided via a distance learning pack. Staff joining the organisation without the appropriate NVQ qualification will be put forward for training once their probationary period has been successfully completed. Three staff hold a relevant NVQ qualification. Four staff are about to commence their NVQ training. Staff files sampled did not contain up to date one to one supervision sessions. The registered manager stated that he was aware that they needed to be undertaken. Please see requirements and recommendations section of this report. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a well run home with a loyal management and staff team. EVIDENCE: The registered manager has undertaken the NVQ Registered Managers award and recently taken part in a session with the Surrey County Council Safeguarding Adults Team. There is a staff rota in place to ensure that residents benefit from a well run home. The registration certificate was on display in the entrance to the home. The service has a Quality Manager in post who undertakes monthly regulation 26 visits. Feedback received from relatives and health care professionals shows that they are satisfied with the service provided. One of the residents stated that he has loved living in Malvern House since day one. Regular Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 21 meetings are held with residents and these are recorded. A programme has begun to update all policies and procedures across the organisation. External contracts are in place with health and safety service providers to check the electrical appliances, fire, gas and to monitor legionella. A maintenance team support the home to maintain compliance with all statutory laws. Regular fire safety checks are carried out and fire drills. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 13 (4) (a) Requirement Risk assessments must be conducted to ensure the safety of people living in the home for windows where restrictors have not been fitted and that action is taken where this is deemed necessary. Staff supervision must be conducted on a 1-1 basis at least six times per year. Timescale for action 31/08/07 2. YA36 18 (2) (a) 31/08/07 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. 2. Refer to Standard YA20 YA24 Good Practice Recommendations It is recommended that all medication practices be audited on a regular basis. It is recommended that the maintenance plan include the following: The redecoration of the lounge and dining room. A kitchen refit including a change of floor covering and the ceiling be made good following the damage caused by the flood in the upstairs bathroom. The extractor fan above the cooker in the kitchen is to be cleaned. The windows at the DS0000013710.V343778.R01.S.doc Version 5.2 Page 24 Malvern 3. YA34 rear of the house downstairs are to be replaced to match the rest of the house. It is recommended that staff attend an infection control training programme. Malvern DS0000013710.V343778.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V343778.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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